The home health nurse visits a young adult client who has AIDS with Kaposi’s sarcoma and peripheral neuropathies. The client’s parents, who are the caretakers, tell the nurse that their child sleeps most of the time.
The nurse assesses that the client is semi-conscious with stable vital signs, cries out in pain when turned or moved, has a fentanyl patch in place, and skin lesions that are closed and dried.
Which intervention should the nurse implement?
Give a complete bed bath to further assess the client.
Remove the fentanyl patch as directed by prescription.
Call for ambulance transportation to the hospital immediately.
Discuss end-of-life decisions with the client’s parents.
The Correct Answer is D
Answer and explanation The correct answer is D. Choice A rationale
Giving a complete bed bath to further assess the client may not be the most appropriate intervention in this case. The client is semi-conscious and cries out in pain when turned or moved. A complete bed bath could potentially cause unnecessary discomfort and distress.
Choice B rationale
Removing the fentanyl patch as directed by prescription may not be the best course of action. Fentanyl is a powerful opioid used to manage severe pain. The client’s parents report that their child cries out in pain when turned or moved, suggesting that the client is experiencing significant pain. Removing the fentanyl patch could potentially exacerbate the client’s pain.
Choice C rationale
Calling for ambulance transportation to the hospital immediately may not be necessary at this time. The client’s vital signs are stable, and there is no indication of an immediate medical emergency based on the information provided.
Choice D rationale
Discussing end-of-life decisions with the client’s parents is the most appropriate intervention. The client is semi-conscious, sleeps most of the time, and is in significant pain. These symptoms suggest that the client’s condition is deteriorating. It is important to have conversations about end-of-life care preferences and decisions to ensure that the client’s wishes are respected and that the parents are prepared.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Answer and explanation
The correct answer is Choice A.
Choice A rationale
Respite care is a service that provides temporary relief to primary caregivers, allowing them time to rest and take care of their own needs. It can be provided in the client’s home, a healthcare facility, or an adult day care center. This service is especially beneficial for caregivers who are feeling exhausted, as it offers them a break while ensuring that their loved ones continue to receive care. Therefore, suggesting that social services be contacted to find a respite care facility for the client would be the best information for the nurse to provide.
Choice B rationale
Hiring a private nurse, also known as concierge nursing, is another option for providing relief to caregivers. However, this option might not be feasible for all families due to the potential cost. Moreover, it might not provide the caregiver with the same level of relief as respite care, as the caregiver might still feel obligated to be involved in the client’s care.
Choice C rationale
A case management evaluation of the client’s home environment could be helpful in assessing the client’s needs and identifying potential resources or modifications that could make caregiving easier. However, this does not directly address the caregiver’s need for rest and relief from their duties.
Choice D rationale
Recommending that the client’s family return to the area to help provide assistance could potentially provide some relief to the caregiver. However, this might not be a feasible or immediate solution, as it depends on the family’s availability and willingness to relocate or travel.
Correct Answer is ["A","B","C","D","E"]
Explanation
Answer and explanation
The correct answers are Choices A, B, C, D, and E.
Choice A rationale
Feeding assistance may be necessary for an older adult with Parkinson’s disease due to motor symptoms like tremors or stiffness that can make self-feeding difficult. Special utensils and other dining aids can help these individuals maintain their independence during meals.
Choice B rationale
People with Parkinson’s disease can experience changes in their skin, such as becoming oily or flaky. While the term “fragile skin” is not typically used in the context of Parkinson’s, these individuals may have skin that is more susceptible to damage due to these changes.
Choice C rationale
Parkinson’s disease often leads to motor symptoms such as stiff muscles and balance impairment, which can increase the risk of falls. Therefore, measures to prevent falls should be a key part of the care plan for an older adult with Parkinson’s disease.
Choice D rationale
Chronic pain is twice as common in people with Parkinson’s disease as it is in people without the condition. This pain can be caused by various factors, including muscle stiffness and dystonia (painful muscle spasms), and should be addressed in the client’s care plan.
Choice E rationale
Depression is more common in people with Parkinson’s disease compared to the general population. It’s important to monitor for signs of depression in these individuals and provide appropriate treatment if necessary.
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