A client has just been informed of a positive HIV test. The client is distraught and does not know what to do. What is the best intervention by the nurse?
Explain the legal requirements to inform sex partners.
Assess the client for support systems.
Offer to inform the family for the client.
Determine if a clergy member would help.
The Correct Answer is B
Choice A rationale:
Explaining legal requirements to inform sex partners at this initial stage is not the most appropriate or supportive intervention.
The client is in a state of emotional distress and may not be receptive to information about legal obligations. It's crucial to first address the client's emotional needs and provide support before discussing legal matters.
Prematurely focusing on legalities could further overwhelm the client and potentially hinder the development of a trusting relationship with the nurse.
Choice C rationale:
Offering to inform the family for the client, while well-intentioned, may not respect the client's autonomy and right to privacy. The decision to disclose HIV status to family members is a personal one that should be made by the client, not the nurse.
It's important to empower the client to make their own choices about disclosure and provide support throughout the process.
Choice D rationale:
Determining if a clergy member would help could be a valuable resource for some clients, but it should not be the first or only intervention.
It's essential to first assess the client's individual needs and preferences regarding spiritual support.
Not all clients may find comfort in religious or spiritual guidance, and some may prefer to seek support from other sources.
Choice B rationale:
Assessing the client for support systems is the most appropriate initial intervention because it focuses on the client's immediate needs for emotional support and connection.
By identifying existing support systems (such as family, friends, or community organizations), the nurse can help the client access resources that can provide comfort, understanding, and assistance in coping with the diagnosis.
This approach recognizes the client's emotional state and prioritizes their psychosocial well-being, which is essential in the initial stages of coping with an HIV diagnosis.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
The correct answer is Choice B.
Choice A rationale: Massaging the site with scented oils is not recommended as it may further irritate the inflamed tissue. Additionally, scented oils can cause allergic reactions or skin irritation, worsening the client's discomfort.
Choice B rationale: Applying warm compresses to the site increases blood flow, reduces inflammation, and provides pain relief. Warm compresses also promote healing by improving circulation and reducing edema, making them an appropriate intervention for phlebitis.
Choice C rationale: Administering topical lidocaine to the site is generally not recommended without a prescription. Although it may provide localized pain relief, it can mask underlying issues and delay appropriate medical assessment and treatment.
Choice D rationale: Administering prescribed oral pain medication can provide systemic pain relief. However, it may not be as effective as a localized treatment for reducing inflammation and discomfort at the site of the peripheral vascular access device.
Correct Answer is B
Explanation
Choice A rationale:
While promptly removing urinary catheters can reduce the risk of catheter-associated urinary tract infections (CAUTIs), it addresses only one specific type of infection. It doesn't comprehensively address other common healthcare-associated infections (HAIs) like central line-associated bloodstream infections (CLABSIs), surgical site infections (SSIs), ventilator-associated pneumonia (VAP), and Clostridium difficile infections (CDI).
Education about infection control methods, however, encompasses a broader range of preventive measures that can be applied to various HAIs, making it a more effective strategy for overall infection prevention.
Choice C rationale:
Placing patients in appropriate isolation can prevent the spread of infections, but it's a reactive measure that's implemented after an infection has already occurred. It doesn't address the root causes of infections or prevent their occurrence in the first place.
Education about infection control methods, on the other hand, is a proactive approach that aims to prevent infections from happening in the first place by teaching staff about proper hygiene practices, aseptic techniques, and other infection prevention strategies.
Choice D rationale:
Monitoring hand hygiene practices is crucial for infection prevention, but it's only one aspect of a comprehensive infection control program. Education about infection control methods goes beyond hand hygiene and covers various other preventive measures, such as:
Proper use of personal protective equipment (PPE) Aseptic technique during invasive procedures
Proper cleaning and disinfection of equipment and surfaces Proper handling of patient waste
Recognition of signs and symptoms of infection Prompt reporting of potential outbreaks
Therefore, educating staff members about infection control methods is the most effective action the nursing manager can take to prevent infections in the hospital unit because it provides a comprehensive approach to infection prevention, addressing various aspects of HAI prevention and promoting a culture of safety among healthcare staff.
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