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 D.

Choice A rationale

While demonstrating proper foot care is important, this client’s situation requires immediate attention. Long, thick nails that curl under the toes can lead to complications such as ulcers, infections, and pain.

Choice B rationale

Gradually trimming the client’s toenails over several visits may not be the best approach. The client’s long, thick nails are causing discomfort and could lead to more serious complications.

Choice C rationale

Arranging for a home health aide to assist the client with hygiene weekly could be part of a long-term plan, but it does not address the immediate issue of the client’s long, thick toenails.

Choice D rationale

Scheduling an appointment for the client with a podiatrist is the best option. A podiatrist is a healthcare professional who specializes in foot care. They can safely trim the client’s long, thick toenails and assess for any other foot-related issues.

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.