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 ["0.75"]
Explanation
Step 1 is 0.1875 mg ÷ 0.25 mg/mL Step 2 is 0.75 mL Final answer: 0.75 mL.
Correct Answer is D
Explanation
Choice A rationale
The client's healthcare power of attorney is important information but not the most urgent detail to report when there is a sudden change in the client's condition. Immediate clinical changes take priority.
Choice B rationale
The fall at home as the reason for admission provides background information but does not address the urgent change in the client's mental status. The primary focus should be on the sudden increase in confusion.
Choice C rationale
Currently prescribed medications are important to consider, especially if they could contribute to the client's confusion. However, the sudden change in mental status is more critical to report first.
Choice D rationale
Increasing confusion of the client is the most urgent information to report. It indicates a significant change in the client's condition that requires immediate assessment and intervention by the healthcare provider. Identifying and addressing the cause of this change is crucial to prevent further complications.
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