Which nursing intervention is a priority when caring for a child with HIV?
Assess pain after invasive procedures.
Review laboratory CD4 counts daily.
Administer prescribed medications.
Assist the child with daily activities.
The Correct Answer is C
Choice A rationale
Pain assessment and management are important components of comprehensive care for any child, including those with HIV, especially following invasive procedures. However, the immediate physiological priority in managing a child with a chronic, immunosuppressive disease like HIV is maintaining immune function and suppressing viral replication through scheduled medication administration to prevent opportunistic infections.
Choice B rationale
Reviewing the absolute CD4+ T-lymphocyte count daily provides information about the degree of immunosuppression, as a normal count for a child varies by age but indicates immune health. While monitoring this parameter is vital for guiding treatment and prophylaxis, the active administration of antiretroviral medications and prophylactic antibiotics is the priority intervention to directly protect the child's immune system.
Choice C rationale
Administering prescribed antiretroviral medications (ART) and prophylactic antibiotics is the priority nursing intervention for a child with Human Immunodeficiency Virus (HIV) infection. Adherence to the ART regimen is critical for maintaining viral suppression, preventing disease progression to AIDS, and preserving the function of the child's severely compromised immune system, thereby reducing the risk of life-threatening opportunistic infections.
Choice D rationale
Assisting the child with daily activities, such as bathing, feeding, and mobility, is part of supportive care. This promotes comfort and physical well-being, especially during periods of illness or fatigue. However, this is a supportive measure, whereas administering medications directly addresses the underlying pathological process of immune deficiency, making medication administration the higher-priority intervention.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["36"]
Explanation
Step 1 is to convert the patient's weight from pounds to kilograms. 59 pounds ÷ 2.2 kg/pound = 26.8181. kg. We will use the unrounded number for the next step.
Step 2 is to calculate the daily fluid requirement based on the Holliday-Segar method. The patient weighs 26.8181. kg, which is more than 20 kg. Fluid for the first 10 kg: 10 kg × 100 mL/kg = 1000 mL. Fluid for the second 10 kg: 10 kg × 50 mL/kg = 500 mL. Remaining weight: 26.8181. kg - 20 kg = 6.8181. kg. Fluid for the remaining weight: 6.8181. kg × 20 mL/kg = 136.3636. mL.
Step 3 is to calculate the total daily fluid requirement. 1000 mL + 500 mL + 136.3636. mL = 1636.3636. mL.
Step 4 is to round the final answer to the nearest whole number. 1636.3636. mL rounded to the nearest whole number is 1636. The daily fluid requirement is 1636 mL.
Correct Answer is A
Explanation
Choice A rationale
Asking "Have you thought about hurting yourself?" is the most therapeutic and appropriate initial response because it directly assesses for suicidal ideation, which is the immediate, life-threatening risk. Stating a wish to not be alive is a direct red flag that requires a non-judgmental, focused follow-up to determine the presence of a plan or intent. A direct question opens the door for the adolescent to disclose critical information needed for immediate safety planning and intervention.
Choice B rationale
Stating "You are just trying to escape your problems" is dismissive and invalidates the adolescent's stated feelings of sadness and despair. This response suggests the feelings are manipulative or weak, which would immediately shut down communication and damage the therapeutic relationship. It fails to address the underlying psychological pain and the immediate safety risk posed by the expression of wanting to be deceased.
Choice C rationale
Stating "Everyone feels sad once in a while" minimizes the severity of the adolescent's statement. While it is true that sadness is a universal emotion, expressing a wish for non-existence goes far beyond normal sadness and signals a severe crisis. Minimizing the feelings can make the adolescent feel misunderstood, ashamed, or isolated, potentially deterring them from sharing necessary details regarding suicidal thoughts or plans.
Choice D rationale
Asking "Have you told your parents how you feel?" shifts the focus away from the immediate priority, which is the adolescent's safety and direct assessment of suicidal intent. While parental involvement is important in pediatric mental health, the immediate responsibility of the nurse is to perform a direct safety assessment and ensure the adolescent is protected before addressing family communication or other support systems. —.
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