A client with genital herpes presents with painful genital ulcers and flu-like symptoms. The nurse is performing an assessment.

What should be the nurse's priority action in this situation?

Choice A rationale:

"I have been experiencing a persistent cough and sore throat." This statement is not indicative of herpes simplex virus (HSV) infection.

Symptoms of HSV infection typically include cold sores, genital ulcers, and itching, but not a persistent cough and sore throat.

Choice B rationale:

"I have noticed painful genital ulcers and itching." This statement describes symptoms of genital herpes, not the cold sores on the lips and face that the client is presenting with.

It is not indicative of the condition described in the question.

Choice C rationale:

"I've had these cold sores for a while; they are really uncomfortable." This statement is indicative of herpes simplex virus infection.

Cold sores on the lips and face are a common manifestation of HSV infection.

The discomfort and persistence of the cold sores align with the typical presentation of the condition.

Choice D rationale:

"I have been feeling extremely fatigued lately." While fatigue can be a symptom of various infections, including viral infections, it is not specific to herpes simplex virus infection.

Fatigue alone is not enough to confirm the diagnosis of HSV infection.

Choice A rationale:

Administering antiviral medications immediately is not the essential nursing action during the assessment of a patient with suspected herpes simplex virus (HSV) infection.

While antiviral medications are used in the treatment of HSV, they should be prescribed by a healthcare provider based on a confirmed diagnosis.

The priority during the assessment is to gather information about the patient's history and symptoms to guide the diagnosis and treatment plan.

Choice B rationale:

Avoiding any contact with the patient to prevent transmission is not an appropriate nursing action during the assessment.

It is essential to maintain standard precautions and use personal protective equipment (PPE) when necessary to prevent potential transmission.

However, avoiding all contact with the patient would hinder the assessment process and the provision of care.

Choice C rationale:

Conducting a thorough medical history and physical examination is the essential nursing action during the assessment of a patient with suspected HSV infection.

Gathering a detailed medical history, including any previous outbreaks or known exposure to HSV, and conducting a physical examination to assess for lesions or symptoms are crucial for diagnosing and managing the condition effectively.

Choice D rationale:

Recommending the patient to start stress-relief exercises is not the essential nursing action during the assessment of HSV infection.

While stress reduction may be beneficial for managing HSV, it is not the primary focus during the initial assessment.

The assessment should primarily focus on gathering information to determine the diagnosis and appropriate treatment plan.