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.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale
Severe motor dysfunction indicates the degree of impairment but does not determine the extent of successful habilitation. Habilitation depends on various factors, including individual capabilities, intervention quality, and environmental support.
Choice B rationale
Brain damage with CP is not progressive, meaning it does not worsen over time. However, the effects and manifestations can vary, leading to a range of functional outcomes. This provides a realistic and hopeful perspective for the child's future.
Choice C rationale
CP is indeed one of the most common permanent physical disabilities in children, but this statement does not directly address the mother's concern about the potential progression of impaired movements.
Choice D rationale
The continued development of the brain lesion is not a characteristic of CP. The brain damage is static, meaning it does not change, although its effects may become more apparent as the child grows and develops.
Correct Answer is D
Explanation
Choice A rationale
An older client one day postoperative with a colostomy for colon cancer may have complex needs that require the expertise of an RN rather than a PN.
Choice B rationale
An older adult scheduled for foot amputation due to diabetes complications may also have complex needs and potential complications that necessitate the supervision of an RN.
Choice C rationale
An adult with alcoholism, cirrhosis, and hepatic encephalopathy is likely to have complex medical issues and require close monitoring and interventions, best suited for an RN.
Choice D rationale
An adult one day postoperative for a laparoscopic cholecystectomy is generally stable and has less complex needs, making them an appropriate assignment for a PN.
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