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A client has a new diagnosis of human immunodeficiency virus (HIV). The client is distraught and does not know what to do. What intervention by the nurse is best?
Assess the client’s support system
Call the hospital clergy to speak with the client.
Explain the legal requirement to tell sex partners
Offer to tell the family for the client
The Correct Answer is A
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","C","E"]
Explanation
Choice A reason: Candidiasis is an opportunistic infection associated with AIDS. Candidiasis is a fungal infection caused by Candida species, which normally live in the mouth, throat, vagina, and intestines. In people with AIDS, the immune system is weakened and cannot control the growth of Candida, leading to oral thrush, esophagitis, vaginitis, or systemic candidiasis.
Choice B reason: Hodgkin's lymphoma is not an opportunistic infection associated with AIDS. Hodgkin's lymphoma is a type of cancer that affects the lymphatic system, which is part of the immune system. It is characterized by the presence of ReedSternberg cells, which are abnormal lymphocytes. The exact cause of Hodgkin's lymphoma is unknown, but it is not related to any specific infection.
Choice C reason: Pneumocystis jiroveci pneumonia is an opportunistic infection associated with AIDS. Pneumocystis jiroveci pneumonia is a fungal infection caused by Pneumocystis jiroveci, which normally lives in the lungs of healthy people without causing any symptoms. In people with AIDS, the immune system is weakened and cannot prevent the invasion of Pneumocystis jiroveci, leading to pneumonia, which is a serious and potentially fatal lung infection.
Choice D reason: Clostridium difficile is not an opportunistic infection associated with AIDS. Clostridium difficile is a bacterial infection caused by Clostridium difficile, which normally lives in the colon of healthy people without causing any problems. In some cases, the use of antibiotics can disrupt the normal balance of bacteria in the colon and allow Clostridium difficile to overgrow and produce toxins, leading to diarrhea, colitis, or pseudomembranous colitis. This infection can affect anyone, regardless of their HIV status.
Choice E reason: NonHodgkin's lymphoma is an opportunistic infection associated with AIDS. NonHodgkin's lymphoma is a type of cancer that affects the lymphatic system, which is part of the immune system. It is characterized by the presence of abnormal lymphocytes, which may be B cells, T cells, or natural killer cells. NonHodgkin's lymphoma is associated with several infections, such as EpsteinBarr virus, human herpesvirus 8, hepatitis C virus, and human Tcell leukemia virus, which may trigger the transformation of lymphocytes in people with AIDS.
Correct Answer is ["A","B","C"]
Explanation
Choice A reason: Cleansing the skin routinely after soiling occurs is an effective intervention to prevent skin injury. This is because soiling from urine, feces, sweat, or wound drainage can irritate the skin and cause inflammation, infection, or breakdown. The nurse should use a gentle cleanser and warm water and pat the skin dry. The nurse should also avoid using harsh chemicals, alcohol, or perfumes on the skin.
Choice B reason: Applying moisturizer to dry areas of skin is an effective intervention to prevent skin injury. This is because dry skin is more prone to cracking, peeling, or tearing. The nurse should use a hypoallergenic moisturizer and apply it to the skin after cleansing and drying. The nurse should also avoid using products that contain alcohol, fragrances, or dyes on the skin.
Choice C reason: Using a Hoyer lift for all transfers is an effective intervention to prevent skin injury. This is because a Hoyer lift is a mechanical device that helps to lift and move the client safely and comfortably. It reduces the friction and shear on the skin by lifting the client off the bed surface and avoiding any sliding or dragging. It also prevents the nurse from injuring themselves by lifting the client manually.
Choice D reason: Massaging the client’s reddened shoulders and heels is not an effective intervention to prevent skin injury. In fact, this may worsen the skin injury by increasing the pressure and damage to the tissues. The nurse should avoid massaging any areas that are reddened, swollen, or blistered, as these are signs of pressure ulcers. The nurse should instead relieve the pressure by repositioning the client or using pressurerelieving devices, such as pillows, foam pads, or air mattresses.
Choice E reason: Repositioning the client once per shift is not an effective intervention to prevent skin injury. This is because repositioning the client once per shift is not frequent enough to prevent the development of pressure ulcers. Pressure ulcers are caused by prolonged pressure on the skin that reduces the blood flow and oxygen to the tissues. The nurse should reposition the client at least every 2 hours or more often if needed, depending on the client's condition and risk factors.
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