A nurse is assisting with the plan of care for a 10-month-old infant who has HIV. Which of the following interventions should the nurse include in the plan?
Monitor the infant's lymphocyte count.
Educate the infant's guardians about exchange transfusions.
Administer granulocyte colony-stimulating factor.
Initiate droplet precautions.
The Correct Answer is A
Monitoring the infant's lymphocyte count is important in evaluating the immune function of the infant. HIV primarily affects the immune system, including lymphocytes. Monitoring the lymphocyte count helps assess the progression of the disease and the effectiveness of treatment.
Exchange transfusions are not typically used in the management of HIV. They are primarily performed in conditions like severe neonatal jaundice or blood disorders, but not for the treatment of HIV.
Granulocyte colony-stimulating factor (G-CSF) is a medication used to stimulate the production of white blood cells called granulocytes. While G-CSF can be used in certain situations, such as to counteract the side effects of certain chemotherapy drugs, it is not a standard treatment for HIV in infants.
Droplet precautions are typically implemented for infectious diseases that spread through respiratory droplets, such as influenza or respiratory syncytial virus (RSV). HIV does not spread through respiratory droplets, so initiating droplet precautions would not be necessary in the care of an infant with HIV.
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Related Questions
Correct Answer is C
Explanation
"My baby will receive the rotavirus immunization orally." - This statement is correct. The rotavirus vaccine is administered orally, typically as drops or as an oral suspension. It is important for the guardian to follow the specific instructions provided by the healthcare provider for the administration of the rotavirus vaccine.
"I should not feed my baby anything for 2 hours prior to an immunization." - This statement is incorrect. It is not necessary to withhold feeding prior to immunizations. In fact, it is generally recommended to feed the baby before the immunization to help provide comfort during the procedure.
"My baby will receive three doses of the meningococcal immunization before kindergarten." This statement is incorrect. The number of doses and the schedule for each immunization may vary. The guardian should consult with the healthcare provider or refer to the immunization schedule for the specific recommendations regarding the meningococcal immunization.
"I should expect my baby to have a high fever for 24 hours after an immunization." - This statement is not entirely accurate. While it is common for infants to experience mild side effects such as a low-grade fever after immunizations, a high fever is less common. The guardian should be aware of the potential side effects and contact the healthcare provider if they have concerns about their baby's reaction to the immunization.
Correct Answer is A
Explanation
This statement accurately reflects the client's own account of what happened, providing important information about the circumstances leading to the fall. Including the client's statement helps document the client's perspective and can contribute to a more comprehensive understanding of the event.
"The client fell because the assistive personnel did not place nonskid slippers on the client." This statement assigns blame to the assistive personnel without sufficient evidence. It is important to maintain objectivity and avoid making assumptions or assigning fault without proper investigation or documentation of facts.
"The client does not appear to have any injuries resulting from the fall." While it is important to assess the client for any injuries after a fall, documenting this information may be more appropriate in the client's assessment or nursing notes rather than in the specific documentation about the fall incident itself.
"An incident report has been completed and sent to risk management." While it is important to report falls and complete an incident report for quality improvement and risk management purposes, this information is more relevant to internal documentation and reporting processes rather than inclusion in the medical record for the client's care.
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