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?

Answer and explanation

The correct answer is Choice B.

Choice A rationale

While reinforcing instructions can boost a patient’s self-confidence, it may not be effective for an elderly patient with Parkinson’s disease who is unable to administer ophthalmic medication due to hand tremors. The physical limitation caused by the tremors may not be overcome by further instruction.

Choice B rationale

If a family member is available and willing to administer the medication, this could be an effective solution. The family member can be trained to administer the medication correctly, ensuring the patient receives their necessary treatment.

Choice C rationale

While obtaining a prescription for a visiting nurse to administer the medication twice a day could ensure the patient receives their medication, it may not be the most practical or cost- effective solution. It also depends on the availability of such services in the patient’s area.

Choice D rationale

Documenting the patient’s inability to administer the medication without assistance is important for record-keeping and communicating with other healthcare providers. However, it does not address the immediate issue of ensuring the patient receives their necessary medication.

Answer and explanation

The correct answer is D.

Choice A rationale

While understanding the characteristics of families in the upper-middle class can provide some insights, it does not give a comprehensive view of the community’s health needs. The income range suggests there are also families with lower incomes, and their health needs might be different.

Choice B rationale

Focusing interventions solely on college-educated individuals could overlook those who do not have a college education but still contribute to the average family income. Health needs can vary widely among individuals regardless of their educational background.

Choice C rationale

While it’s important to verify the reliability of the high average family income, it does not directly inform the nurse about the community’s health needs. Income is just one aspect of a community’s demographic profile.

Choice D rationale

Understanding the frequency of incomes above and below the average can help the nurse identify income inequality within the community. This information is crucial as income inequality can impact access to healthcare services and health outcomes.