A client who was a victim of a rape and was confirmed HIV positive six months ago arrives at the clinic for an appointment.
The client is thin, with a saddened affect and talks about frequently crying and feeling hopeless.
The client describes not wanting to see anyone or go out of the house.
Which action should the nurse take?
Explain the ELISA test will be needed to confirm the results.
Identify support systems in the client's life.
Inquire about plans to further education.
Explore feelings of hope for the future.
Inquire about plans to further education.
The Correct Answer is B
Choice A rationale
Explaining the ELISA test for confirmation is unnecessary as the client is already confirmed HIV positive. Repeating the test may cause confusion and anxiety without offering additional benefit at this stage.
Choice B rationale
Identifying support systems in the client's life is crucial for addressing the emotional and psychological impact of being HIV positive and a victim of rape. Support systems, such as family, friends, or support groups, can provide the necessary emotional support and practical assistance to help the client cope with the challenges.
Choice C rationale
Inquiring about plans to further education may not be timely or appropriate in the context of the client's current emotional state. The priority should be addressing the client's immediate mental health needs and ensuring they have adequate support systems in place.
Choice D rationale
Exploring feelings of hope for the future is important but may not be the immediate priority. The client is currently experiencing significant emotional distress, so addressing their immediate mental health needs and ensuring support is a higher priority.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","D"]
Explanation
Choice A rationale: Oxygen saturation of 56% is critically low and indicates severe hypoxemia, which requires immediate intervention to improve oxygenation and prevent life-threatening complications.
Choice D rationale: Tracheal deviation to the right suggests a possible tension pneumothorax, which is a medical emergency. It requires immediate attention to relieve the pressure on the affected lung and restore normal breathing.
Choice B rationale: Crackles heard in the right lung indicate fluid or atelectasis but are not immediately life-threatening compared to the other findings.
Choice C rationale: A pH of 7.21 indicates acidemia and respiratory acidosis but is a secondary concern compared to the immediate need to address the client's hypoxemia and potential tension pneumothorax.
Correct Answer is A,C,B
Explanation
Choice A rationale
Noting the date and time of the behavior is the first step in addressing the issue, providing a record for future reference and ensuring accuracy in documentation.
Choice C rationale
Planning for scheduled break times helps address potential reasons for the behavior, offering a structured solution to prevent recurrence and improve overall workflow.
Choice B rationale
Evaluating the UAP for signs of improvement is the final step, assessing whether the implemented interventions have been effective and if further actions are needed.
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