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
Identifying the issue the facility is facing is an important step in addressing the communication issue. However, it is not the only action that should be taken. The Incident Command team should also determine actions to address the issue, identify parameters to monitor, and consider all of these steps together.
Choice B rationale
Determining actions to address the issue is an important step in addressing the communication issue. However, it is not the only action that should be taken. The Incident Command team should also identify the issue, identify parameters to monitor, and consider all of these steps together.
Choice C rationale
Identifying parameters to monitor to ensure all essential personnel are aware of the communication tree is an important step in addressing the communication issue. However, it is not the only action that should be taken. The Incident Command team should also identify the issue, determine actions to address the issue, and consider all of these steps together.
Choice D rationale
All of the above actions should be taken to address the communication issue. The Incident Command team should identify the issue the facility is facing, determine actions to address the issue, and identify parameters to monitor to ensure all essential personnel are aware of the communication tree. By considering all of these steps together, the Incident Command team can effectively address the communication issue and improve communication within the facility.
Correct Answer is D
Explanation
Answer and explanation
The correct answer is Choice D.
Choice A rationale
The number of requests for pregnancy testing being higher than last year does not necessarily indicate that the Healthy People 2030 objectives are being addressed. It could suggest an increase in sexual activity among the students, which could lead to an increase in sexually transmitted infections or unplanned pregnancies if not managed properly.
Choice B rationale
A decrease in the number of sick days could suggest an improvement in the overall health of the students. However, it does not provide a comprehensive picture of the health status of the students. Other factors, such as the number of students participating in physical education or the overall health of the student population, should also be considered.
Choice C rationale
An increase in the number of students participating in physical education could suggest an improvement in the physical health of the students. However, it does not provide a comprehensive picture of the health status of the students. Other factors, such as the number of sick days or the overall health of the student population, should also be considered.
Choice D rationale
An improvement in the overall health of the student population is the best indication that the Healthy People 2030 objectives are being addressed. The Healthy People 2030 objectives aim to improve health and well-being nationwide. Therefore, an improvement in the overall health of the student population suggests that these objectives are being met.
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