During the first trimester of pregnancy, a client who was treated for genital herpes with acyclovir prior to this pregnancy tells the practical nurse (PN) that she is experiencing an episode of genital herpes.
Which nursing intervention has the highest priority?
Assess her feelings about therapeutic abortions in the event the infant has been affected
Identify current sexual partners so that they can be evaluated and treated for genital herpes if necessary.
Instruct her to avoid sexual intercourse while active, visible lesions are present.
Determine if the client has taken acyclovir for this outbreak of genital herpes.
The Correct Answer is C
A. Assess her feelings about therapeutic abortions in the event the infant has been affected. - While important to address concerns, the immediate priority is to manage the current outbreak and prevent transmission.
B. Identify current sexual partners so that they can be evaluated and treated for genital herpes if necessary. - Contact tracing is important but not the highest priority in managing the current outbreak.
C. Instruct her to avoid sexual intercourse while active, visible lesions are present. - This is crucial to prevent transmission of the herpes virus to the sexual partner and to reduce the risk of complications for the pregnancy.
D. Determine if the client has taken acyclovir for this outbreak of genital herpes. - While important for understanding the treatment history, instructing the client on preventive measures has a higher priority.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Locate where in the body the pain occurs. - While important, this information is relevant for understanding the pain's origin but may not necessarily capture changes in pain intensity after administering analgesics.
B. Apply a pain scale to describe the intensity. - This is crucial to assess the effectiveness of the analgesic. Changes in pain intensity post-medication can indicate the efficacy of the intervention.
C. Ask about elements of the pain experience. - This encompasses various aspects of pain but might not directly measure the immediate impact of the analgesic.
D. Question the client about precipitating factors. - While helpful for understanding triggers, it may not be as immediately relevant for assessing the analgesic's effect.
Correct Answer is B
Explanation
A. Sodium level of 130 mEq/L is slightly below the lower limit of the reference range but might not have as immediate an impact on safety as a critically low hemoglobin level.
B. Hemoglobin of 8.9 grams/dL is significantly below the normal range and indicates a substantial drop in red blood cells, which can lead to impaired oxygen transport and potentially severe postoperative complications like inadequate tissue perfusion and oxygenation.
C. Potassium level of 3.4 mEq/L is slightly below the lower limit of the reference range but might not pose an immediate threat compared to a critically low hemoglobin level.
D. Blood urea nitrogen (BUN) of 20 mg/dL is at the upper limit of the reference range but might not have an immediate implication for client safety compared to a critically low hemoglobin level.
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