The nurse is providing education to a client regarding the administration of eye drops. Which of the following actions indicates the need for further client education?
The client instills the prescribed number of eye drops into the conjunctival sac.
The client washes her hands before instilling the eye drops.
The client sets the cap to the eye drop container down in a manner that does not contaminate it.
The client touches the administration dropper to the eye.
The Correct Answer is D
Choice A reason: The client instills the prescribed number of eye drops into the conjunctival sac is a correct action, because it ensures that the medication reaches the eye surface and does not spill out. The conjunctival sac is the space between the eyelid and the eyeball.
Choice B reason: The client washes her hands before instilling the eye drops is a correct action, because it prevents the introduction of microorganisms or foreign substances into the eye. Hand hygiene is an essential infection control measure.
Choice C reason: The client sets the cap to the eye drop container down in a manner that does not contaminate it is a correct action, because it preserves the sterility of the eye drop solution and prevents crosscontamination. The cap should be placed on a clean surface with the inner side facing up.
Choice D reason: The client touches the administration dropper to the eye is an incorrect action, because it can cause injury, infection, or contamination of the eye drop solution. The administration dropper should be held close to the eye, but not touch it.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason: This is the correct statement because it reflects the fact that reexposure to HIV can increase the viral load and accelerate the decline of the immune system. HIV is a virus that infects and destroys the CD4 cells, which are the white blood cells that help fight infections. AIDS is the final stage of HIV infection, when the CD4 count falls below 200 cells/mm3 or the client develops an opportunistic infection. The progression from HIV to AIDS can vary from person to person, depending on several factors, such as viral strain, genetic factors, treatment adherence, and coinfections. Reexposure to HIV can expose the client to a different or more aggressive strain of the virus, which can overwhelm the immune system and hasten the development of AIDS.
Choice B reason: This is an incorrect statement because it ignores the role of nutrition in maintaining the health and function of the immune system. Diet can influence the progression of HIV to AIDS by affecting the client's weight, energy, metabolism, and susceptibility to infections. The client should eat a balanced and varied diet that provides adequate calories, protein, vitamins, minerals, and fluids. The client should also avoid foods that can cause diarrhea, dehydration, or food poisoning, which can worsen the symptoms and complications of HIV infection.
Choice C reason: This is an incorrect statement because it contradicts the evidence that shows that meditation can have positive effects on the psychological and physiological wellbeing of people living with HIV. Meditation is a mindbody practice that involves focusing attention on the present moment, breathing, and relaxation. Meditation can help the client cope with stress, anxiety, depression, and pain, which are common challenges for people living with HIV. Meditation can also improve the immune system function by reducing inflammation, oxidative stress, and cortisol levels, which can slow down the progression of HIV to AIDS.
Choice D reason: This is an incorrect statement because it overlooks the impact of sexually transmitted infections (STIs) on the course of HIV infection. STIs can increase the risk of transmitting and acquiring HIV by causing ulcers, inflammation, or bleeding in the genital area, which can facilitate the entry and exit of the virus. STIs can also increase the viral load and decrease the CD4 count, which can speed up the progression of HIV to AIDS. The client should practice safe sex by using condoms, getting tested and treated for STIs, and informing their sexual partners about their HIV status.
Correct Answer is A
Explanation
Choice A reason: This is the best intervention because it helps the nurse to understand the client's emotional, social, and practical needs and resources. A new diagnosis of HIV can be a devastating and overwhelming experience for the client, who may face stigma, discrimination, isolation, or rejection from others. The nurse should assess the client's support system, such as family, friends, or community groups, that can provide comfort, guidance, and assistance to the client. The nurse should also encourage the client to seek professional counseling, peer support, or other services as needed.
Choice B reason: This is not the best intervention because it may not respect the client's preferences, beliefs, or values. The nurse should not assume that the client wants or needs spiritual or religious support, unless the client expresses such a desire. The nurse should ask the client about their spiritual or religious beliefs and practices and provide appropriate referrals or resources as requested by the client. The nurse should also respect the client's right to privacy and confidentiality and not disclose the client's diagnosis to anyone without the client's consent.
Choice C reason: This is not the best intervention because it may not be the most urgent or appropriate topic to discuss with the client at this time. The nurse should not focus on the legal or ethical aspects of the client's diagnosis, but rather on the client's emotional and physical wellbeing. The nurse should explain the legal requirement to tell sex partners in a sensitive and respectful manner, but only after the client has accepted and understood their diagnosis and has expressed readiness to disclose their status to others. The nurse should also provide the client with information and resources on how to prevent the transmission of HIV and how to protect themselves and their partners.
Choice D reason: This is not the best intervention because it may not be the client's wish or choice. The nurse should not offer to tell the family for the client, unless the client asks for such help. The nurse should respect the client's autonomy and decisionmaking regarding whom to tell and when to tell about their diagnosis. The nurse should also support the client in preparing for the possible reactions and outcomes of disclosing their status to their family and others.
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