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
Converting written vehicle instructions into a pictorial format can help improve understanding, but it does not directly address the physical dangers associated with the machinery.
Choice B rationale
Educating farm workers not to smoke around farm equipment can prevent fires, but it does not directly reduce the risk of machinery-related injuries.
Choice C rationale
Offering rehabilitation services to injured farm workers is important, but it is a reactive measure. The goal should be to prevent injuries from occurring in the first place.
Choice D rationale
Collaborating with lawmakers to mandate safe tractor design can have a significant impact on reducing farm machinery injuries. By addressing the issue at the design level, many injuries can be prevented.
Correct Answer is A
Explanation
Answer and explanation
The correct answer is Choice A.
Choice A rationale
Conducting interviews with community members is a crucial first step when evaluating a community's health promotion needs[^30^]³²³³³?. These interviews can provide valuable insights into the community's health concerns, behaviors, and needs. They can also help
identify barriers to health promotion and potential strategies for overcoming these
barriers[^30^]³²³³³?.
Choice B rationale
Organizing a health fair for the entire community can be a valuable health promotion strategy. However, it would not typically be the first step in evaluating a community's health promotion needs. Before organizing such an event, it would be important to understand the specific health concerns, behaviors, and needs of the community, which could be achieved through methods such as interviews with community members[^30^]³²³³³?.
Choice C rationale
Forecasting future healthcare needs is an important aspect of health promotion planning. However, it would not typically be the first step in evaluating a community's health promotion needs. Before forecasting future needs, it would be important to understand the current health concerns, behaviors, and needs of the community, which could be achieved through methods such as interviews with community members[^30^]³²³³³?.
Choice D rationale
Assessing the outcomes of previous projects can provide valuable insights for future health promotion efforts. However, it would not typically be the first step in evaluating a community's health promotion needs. Before assessing previous outcomes, it would be important to understand the current health concerns, behaviors, and needs of the community, which could be achieved through methods such as interviews with community members[^30^]³²³³³?.
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