The home health practical nurse (PN) visits a young male client with AIDS who has Kaposi's sarcoma and peripheral neuropathies. His parents, who provide care for the client, report that their son sleeps most of the time. The PN observes the client is semi-conscious with stable vital signs and cries out in pain when turned or moved. A fentanyl patch is in place and skin lesions are closed and dried. Which intervention should the PN implement?
Give a complete bed bath to further assess the client.
Discuss end-of-life decisions with the client's parents.
Call for ambulance transportation to the hospital immediately.
Remove the fentanyl patch as directed by prescription.
The Correct Answer is B
A. Give a complete bed bath to further assess the client:
This could cause unnecessary pain and discomfort; comfort is the priority.
B. Discuss end-of-life decisions with the client's parents:
The client appears to be in the terminal stage of AIDS. It is appropriate to initiate discussions about palliative and hospice care with family.
C. Call for ambulance transportation to the hospital immediately:
The client’s condition is not unstable; hospitalization may not be indicated at this stage.
D. Remove the fentanyl patch as directed by prescription:
Removing pain control would worsen suffering unless there is a prescription change for adverse effects.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Report findings to supervisor for referral to APS: Mandatory reporting protects client safety.
B. Ask daughter who has been caring for client: May alert potential abuser and place client at further risk.
C. Apply dry dressings after cleansing wounds: Necessary, but safety and reporting take precedence.
D. Document the lacerations: Must be done, but immediate action is reporting.
Correct Answer is C
Explanation
A. Talkativeness: Seen during intoxication, not withdrawal.
B. Exhilaration: Associated with the stimulant effects of cocaine, not withdrawal.
C. Extreme drug craving: Withdrawal is characterized by intense cravings, fatigue, depression, and irritability.
D. Increased energy: Seen during intoxication, not during withdrawal.
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