During the first trimester of pregnancy, a client who was treated for genital herpes with acyclovir prior to this pregnancy tells the practical nurse (PN) that she is experiencing an episode of genital herpes.

Which nursing intervention has the highest priority?

Assess her feelings about therapeutic abortions in the event the infant has been affected

Identify current sexual partners so that they can be evaluated and treated for genital herpes if necessary.

Instruct her to avoid sexual intercourse while active, visible lesions are present.

Determine if the client has taken acyclovir for this outbreak of genital herpes.

Answer and Explanation

The Correct Answer is C

A.   Assess her feelings about therapeutic abortions in the event the infant has been affected. - While important to address concerns, the immediate priority is to manage the current outbreak and prevent transmission.
B.   Identify current sexual partners so that they can be evaluated and treated for genital herpes if necessary. - Contact tracing is important but not the highest priority in managing the current outbreak.
C.   Instruct her to avoid sexual intercourse while active, visible lesions are present. - This is crucial to prevent transmission of the herpes virus to the sexual partner and to reduce the risk of complications for the pregnancy.
D.   Determine if the client has taken acyclovir for this outbreak of genital herpes. - While important for understanding the treatment history, instructing the client on preventive measures has a higher priority.

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Correct Answer is B

Explanation

A. Requesting that the man leave violates the patient's right to privacy and intimacy.
B. In this situation, the practical nurse (PN) shouldexit the room and quietly close the door. This approach respects the privacy and dignity of the older female client and her male friend while maintaining professionalism and discretion. It avoids embarrassing or shaming the couple and allows them their personal space.
C. Asking when the nurse should return doesn't handle the immediate situation effectively.
D. Reporting the incident to the family might be an option, but the immediate action is to maintain appropriate boundaries by asking the man to leave.

A. Ask the client if he finished the bowel sterilization prescription. B. Review the client's expectations of elimination after surgery. C. Verify that the client had nothing by mouth (NPO) for the past 24 hours. D. Determine if this is the first indwelling catheter the client has had.

Correct Answer is B

Explanation

A. Asking about the bowel sterilization prescription doesn't address the client's concern regarding the visibility of the surgical opening.
B. Reviewing the client's expectations after surgery could address the client's query about the visibility of the surgical opening and offer information regarding elimination.
C. Verifying the NPO status is important for surgery preparation but doesn’t directly address the client's specific concern.
D. Determining if this is the first indwelling catheter doesn’t directly address the client's immediate concern regarding the surgical opening.

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During the first trimester of pregnancy, a client who was treated for genital herpes with acyclovir prior to this pregnancy tells the practical nurse (PN) that she is experiencing an episode of genital herpes. Which nursing intervention has the highest priority?

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Naxlex Comprehensive Predictor Exams

An older female client who resides in a long-term care facility has a male friend who often visits her in the evenings. The practical nurse (PN) enters the room to administer medications and finds the couple in bed together. What action should the PN take?

Correct Answer is B

Explanation

The practical nurse (PN) is assisting with preparation of a client for fecal diversion surgery. While inserting an indwelling urinary catheter, the client asks if the surgical opening will be visible. Which action should the PN implement?

Correct Answer is B

Explanation

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A client is scheduled for a thoracentesis that will be done at the bedside. What should the practical nurse (PN) prepare before the healthcare provider arrives on the unit to perform the procedure?

During the first trimester of pregnancy, a client who was treated for genital herpes with acyclovir prior to this pregnancy tells the practical nurse (PN) that she is experiencing an episode of genital herpes.

Which nursing intervention has the highest priority?