While receiving report for a client with carcinoma in situ of the left breast, the practical nurse (PN) reviews a pending lab report and notices increased levels of Anti-Glycan Neu5Gc Antibodies (AGNA). Which changes should the PN anticipate to be included in the client's plan of care?
Initiation of changes in infection control measures
Increasing the client's dietary servings of fruits and vegetables
Limiting the client's fluid intake to avoid hemodilution
Avoiding the client's exposure to cold temperatures
The Correct Answer is A
- Anti-Glycan Neu5Gc Antibodies (AGNA) are antibodies that recognize a carbohydrate antigen called N- glycolylneuraminic acid (Neu5Gc), which is found in animal-derived foods and tissues, but not in humans. Humans can incorporate Neu5Gc from their diet into their own cells, which can trigger an immune response and the production of AGNA.
- AGNA have been associated with various inflammatory and autoimmune diseases, such as atherosclerosis, rheumatoid arthritis, Crohn's disease, and cancer. AGNA may also play a role in the rejection of bioprosthetic heart valves, which are made from animal tissues that contain Neu5Gc.
- A client with carcinoma in situ of the left breast is a client with a non-invasive form of breast cancer, where the abnormal cells are confined to the ducts or lobules of the breast. This type of cancer has a high chance of cure with surgery and/or radiation therapy.
- Increased levels of AGNA in a client with carcinoma in situ of the left breast may indicate that the client has an increased risk of inflammation and infection, as AGNA can activate the complement system and recruit inflammatory cells to the site of Neu5Gc expression. This may impair the healing process and increase the chances of complications after surgery or radiation therapy.
Therefore, the practical nurse (PN) should anticipate that the client's plan of care will include initiation of changes in infection control measures, such as prophylactic antibiotics, wound care, sterile dressing changes, and monitoring for signs and symptoms of infection (such as fever, redness, swelling, pain, or pus). These measures will help to prevent or treat any potential infection and promote wound healing.
Therefore, option A is the correct answer, while options B, C, and D are incorrect.
Option B is incorrect because increasing the client's dietary servings of fruits and vegetables may not have a significant impact on the levels of AGNA or Neu5Gc in the client's body.
Option C is incorrect because limiting the client's fluid intake to avoid hemodilution may not be necessary or beneficial for the client's condition.
Option D is incorrect because avoiding the client's exposure to cold temperatures may not be relevant or helpful for the client's condition.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["C","D","E"]
Explanation
A.The client's weight has remained relatively stable (83.9 kg to 83 kg), which does not indicate an immediate health concern compared to the acute behavioral and mental health symptoms observed.
B. While the client's neurostatus (mental status) is affected by the presence of auditory hallucinations, pressured speech, and restlessness, these symptoms are more critical in terms of immediate management than a general assessment of neurologic status.
C. Auditory hallucinations, such as appearing to listen to unseen others, are concerning symptoms indicating possible exacerbation of schizophrenia or medication non-compliance. Immediate assessment and intervention by mental health professionals are needed.
D.Pressured speechis commonly seen in mania or anxiety.Poverty of speechcan be associated with shyness, depression, schizophrenia, or cognitive impairment. Pressured speech noted along with other symptoms can indicate agitation or worsening of mental health symptoms. It suggests the client may be experiencing an acute phase of their illness, requiring evaluation and possibly adjustment of medications.
E. Restlessness, frequently getting out of the chair, and appearing tired and disheveled indicate agitation and potential agitation or anxiety. This could be a sign of increased agitation, anxiety, or distress, which needs immediate attention to prevent escalation.
Correct Answer is B
Explanation
A. "Perhaps you think the ECT is dangerous, but I've seen it have good results." This response is dismissive of the client's concerns and implies that the nurse knows better than the client.
B. "You have the right to change your mind about this procedure at any time." This response respects the client's autonomy and informs them of their rights.
C. "Everyone gets a little nervous about this procedure as the time for it approaches." This response minimizes the client's feelings and assumes that they are experiencing normal anxiety.
D. "Your doctor wouldn't have suggested ECT if they didn't think it would help you." This response shifts the responsibility to the doctor and does not address the client's fears.
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