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 D
Explanation
Answer and explanation
The correct answer is Choice D.
Choice A rationale
While older adults living in subsidized housing near an airport may have exposure to various environmental hazards, lead poisoning is not typically associated with these conditions. Lead poisoning is more commonly associated with exposure to lead-based paint, which is often found in older homes.
Choice B rationale
Young adults who frequently camp and hike in remote desert areas are not typically at high risk for lead poisoning. Lead exposure is more commonly associated with certain occupational environments and older residential buildings.
Choice C rationale
While a diet high in fish and other seafood can expose individuals to certain environmental contaminants, lead poisoning is not typically associated with these food sources. Lead exposure is more commonly associated with certain occupational environments and older residential buildings.
Choice D rationale
Families with young children living primarily in 100-year-old farmhouses would likely benefit most from a lead poisoning education and screening program. Older homes, particularly those built before 1978, often contain lead-based paint, which can pose a significant risk for lead poisoning, especially in young children.
Correct Answer is C
Explanation
Answer and explanation
The correct answer is Choice C.
Choice A rationale
While an annual health fair can provide valuable health screenings and education, it may not be the most critical resource for a rural community.
Choice B rationale
A family planning center can offer important services, but it may not be the most urgent need for the entire community.
Choice C rationale
Access to trauma care is crucial in rural areas where distances to hospitals can be great. Injuries and acute illnesses require immediate attention, and having access to trauma care can significantly improve outcomes.
Choice D rationale
While a plan for weather-related disasters is important, it does not address the everyday healthcare needs of the community.
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