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
This response allows the nurse to express genuine interest in the client's perspective and opens up a dialogue to understand the client's concerns or reasons for refusing to learn how to self-administer insulin. It provides an opportunity for the client to express their fears, doubts, or any barriers they may have. By actively listening to the client, the nurse can better address their concerns and provide appropriate education and support tailored to their individual needs.
The other options may come across as confrontational, judgmental, or unhelpful in establishing a therapeutic relationship with the client. It is important for the nurse to approach the situation with empathy, respect, and a non-judgmental attitude to foster effective communication and promote the client's engagement in their own care.
Correct Answer is B
Explanation
By using short, simple sentences, the nurse can effectively communicate with the client who is exhibiting signs of agitation and anxiety. This communication style can help reduce stress and confusion for the client and promote understanding.
Asking the client if they would like to watch television: While providing options for activities can be beneficial, it is important to address the client's current state of agitation and anxiety before suggesting any specific activities.
Allowing the client to have 1 hour of time alone in their room: While some clients may prefer solitude, in this case, the client's pacing and hand-wringing indicate signs of distress and may require therapeutic interventions rather than isolation.
Moving the client to a table where other clients are playing cards: This option may not address the client's current state of anxiety and pacing. Placing the client in a social setting with other clients might increase their distress and agitation.
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