During the first trimester of pregnancy, a client who was treated for genital herpes with acyclovir prior to this pregnancy tells the practical nurse (PN) that she is experiencing an episode of genital herpes. Which nursing intervention has the highest priority?
Assess her feelings about therapeutic abortions in the event the infant has been affected.
Identify current sexual partners so that they can be evaluated and treated for genital herpes if necessary.
Instruct her to avoid sexual intercourse while active, visible lesions are present.
Determine if the client has taken acyclovir for this outbreak of genital herpes.
The Correct Answer is C
A. Assess her feelings about therapeutic abortions in the event the infant has been affected. - While important to consider potential outcomes, immediate care involves preventing transmission and managing the current outbreak.
B. Identify current sexual partners so that they can be evaluated and treated for genital herpes if necessary. - Contact tracing is important but not the highest priority in managing the current outbreak.
C. Instruct her to avoid sexual intercourse while active, visible lesions are present. - This is crucial to prevent transmission of the herpes virus to the sexual partner and to reduce the risk of complications for the pregnancy.
D. Determine if the client has taken acyclovir for this outbreak of genital herpes. - While important for understanding the treatment history, instructing the client on preventive measures has a higher priority.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Allowing the client to go to the bathroom independently may pose a safety risk, particularly if the labor progresses rapidly or if she experiences increased discomfort.
B. Assisting the client to the bathroom might not be advisable if she is in active labor, as her condition can change quickly, and she may need immediate access to care.
C. Offering the client a bedpan or urinal would allow for bladder emptying but may not address the urgency of her desire to ambulate.
D. Encouraging the client to hold off until she is further dilated is appropriate, as a full bladder can impede labor progression and lead to complications. This allows for monitoring and assessment of her condition, ensuring that she remains safe and that labor can continue effectively.
Correct Answer is A
Explanation
A. Determining the means of evacuation requires understanding the facility's evacuation protocols, coordinating with authorities, and ensuring the safety of residents, which typically falls under the responsibility of the nursing staff, including the practical nurse (PN).
B. Closing fire doors and residents' room doors can be part of fire safety protocols and may involve the immediate safety response handled by both nursing staff and facility personnel.
C. Assisting wandering residents and offering comfort and reassurance to distraught residents can be tasks shared among nursing and support staff to ensure resident safety and well-being during an emergency situation.
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