A client is tested for human immunodeficiency virus (HIV) infection with an enzyme- linked immunosorbent assay (ELISA), and the test result & positive. What would the nurse tell the client?

You probably have a gastrointestinal infection*

"You are confirmed to be infected with the HIV virus.

This is a good result, which means you do not have HIV."

Your result will need to be confirmed with a Western blot test."

Answer and Explanation

The Correct Answer is D

A. "You probably have a gastrointestinal infection":
This statement is incorrect. A positive result on the enzyme-linked immunosorbent assay (ELISA) indicates the presence of antibodies to HIV, which suggests exposure to the virus. It does not point to a gastrointestinal infection. HIV is a viral infection that primarily affects the immune system, not the gastrointestinal system. Misleading the client in this way would delay proper care and understanding of their health status.

B. "You are confirmed to be infected with the HIV virus.":
A positive ELISA test result does not automatically confirm an HIV diagnosis. ELISA is a screening test that detects HIV antibodies, but it can sometimes produce false-positive results. A positive ELISA result must be confirmed with a more specific confirmatory test, such as the Western blot test. Therefore, it would be premature to tell the client that they are "confirmed" to be infected with HIV without further confirmatory testing.

C. "This is a good result, which means you do not have HIV.":
This statement is also incorrect. A positive ELISA test result does not mean that the client does not have HIV. In fact, it indicates potential exposure to the virus. However, because the result is a screening test, it must be followed up with confirmatory testing. Telling the client that this is a "good result" would be misleading and could cause confusion or delay in appropriate care.

D. "Your result will need to be confirmed with a Western blot test.":
This is the correct response. The Western blot test is the confirmatory test used to verify a positive result from the ELISA. If the ELISA result is positive, the client should be informed that further testing, such as the Western blot, is needed to confirm the diagnosis of HIV infection. It is important to explain that the ELISA is a screening tool, and a positive result does not mean a definitive diagnosis without confirmation. This helps to set realistic expectations and ensures the client receives the appropriate follow-up care.

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Correct Answer is C

Explanation

A. Auscultate the client’s apical pulse for a full minute:
While auscultating the apical pulse is important for certain cardiovascular conditions, it is not the primary action needed before administering sublingual nitroglycerin. The nurse's main priority is to assess the patient's blood pressure, as nitroglycerin can cause significant hypotension (a drop in blood pressure), and it is important to ensure the patient’s blood pressure is adequate before administration. If the blood pressure is too low, nitroglycerin should not be given.

B. Advise the client that vomiting is a primary side effect:
Vomiting is not a primary or common side effect of sublingual nitroglycerin. Nitroglycerin is more likely to cause headaches, dizziness, flushing, and hypotension. While it’s helpful to inform the patient about possible side effects, advising them that vomiting is a primary side effect could cause unnecessary concern or confusion.

C. Check the client’s blood pressure:
This is the correct action. Nitroglycerin works by dilating blood vessels, which can lower blood pressure. Before administering sublingual nitroglycerin, it is essential to check the client's blood pressure. If the client is hypotensive or has low blood pressure, nitroglycerin should be withheld, as it could further decrease blood pressure and worsen the patient’s condition. This is the priority nursing action to ensure the patient’s safety.

D. Obtain a STAT chest X-ray:
Obtaining a chest X-ray is not a priority action for a client with unstable angina before administering nitroglycerin. Chest X-rays are more useful for diagnosing conditions like pneumonia, pneumothorax, or other structural issues of the chest, but they are not immediately needed in the management of unstable angina. The most immediate concern is assessing the patient’s blood pressure before administering nitroglycerin.

A. Sedate the client with PRN medications so they stay in bed B. Implement the bed alarm and call light system C. Ensure all four side rails on the bed are up D. Avoid night lights in the client's room to promote sleep

Correct Answer is B

Explanation

A. Sedate the client with PRN medications so they stay in bed:
Sedating a client to prevent movement is not an appropriate intervention for fall prevention. This approach could have adverse effects, such as increased confusion, sedation, and even a greater risk for falls once the medication wears off. It may also contribute to a decreased level of independence and quality of life for the client. Non-pharmacological interventions such as environmental modifications and supportive devices should be prioritized.

B. Implement the bed alarm and call light system:
Implementing a bed alarm and call light system is an effective and appropriate strategy to prevent falls in an older adult client. The bed alarm alerts the healthcare team when the client attempts to get out of bed, reducing the risk of falls. The call light allows the client to request assistance before attempting to move independently, ensuring timely support and reducing fall risk. This intervention promotes safety while maintaining the client’s autonomy.

C. Ensure all four side rails on the bed are up:
While side rails may prevent a client from falling out of bed, raising all four side rails can increase the risk of injury. Clients may try to climb over the rails, which can lead to entrapment or falls. In addition, side rails can create a false sense of security and reduce the client's ability to mobilize independently. A more appropriate measure would be using one or two side rails or providing assistance with repositioning or transferring when necessary.

D. Avoid night lights in the client's room to promote sleep:
Avoiding night lights is not advisable for older adults, particularly those at risk for falls. A dark environment can increase confusion and disorientation, leading to unsafe movements. Providing soft night lights in the room can enhance visibility during nighttime hours, reducing the likelihood of accidents and falls when the client needs to get up to use the bathroom or reposition. Adequate lighting is a key aspect of fall prevention.

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A client is tested for human immunodeficiency virus (HIV) infection with an enzyme- linked immunosorbent assay (ELISA), and the test result & positive. What would the nurse tell the client?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is caring who presented with unstable angina. Before giving the client, a dose of sublingual nitroglycerin, which action should the nurse take?

Correct Answer is C

Explanation

The nurse is caring for an older adult client who is at risk for falls. Which of the following interventions should be included in the plan of care for this client?

Correct Answer is B

Explanation

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