A client is tested for human immunodeficiency virus (HIV) infection with an enzyme- linked immunosorbent assay (ELISA), and the test result & positive. What would the nurse tell the client?

You probably have a gastrointestinal infection*

"You are confirmed to be infected with the HIV virus.

This is a good result, which means you do not have HIV."

Your result will need to be confirmed with a Western blot test."

Answer and Explanation

The Correct Answer is D

A. "You probably have a gastrointestinal infection":
This statement is incorrect. A positive result on the enzyme-linked immunosorbent assay (ELISA) indicates the presence of antibodies to HIV, which suggests exposure to the virus. It does not point to a gastrointestinal infection. HIV is a viral infection that primarily affects the immune system, not the gastrointestinal system. Misleading the client in this way would delay proper care and understanding of their health status.

B. "You are confirmed to be infected with the HIV virus.":
A positive ELISA test result does not automatically confirm an HIV diagnosis. ELISA is a screening test that detects HIV antibodies, but it can sometimes produce false-positive results. A positive ELISA result must be confirmed with a more specific confirmatory test, such as the Western blot test. Therefore, it would be premature to tell the client that they are "confirmed" to be infected with HIV without further confirmatory testing.

C. "This is a good result, which means you do not have HIV.":
This statement is also incorrect. A positive ELISA test result does not mean that the client does not have HIV. In fact, it indicates potential exposure to the virus. However, because the result is a screening test, it must be followed up with confirmatory testing. Telling the client that this is a "good result" would be misleading and could cause confusion or delay in appropriate care.

D. "Your result will need to be confirmed with a Western blot test.":
This is the correct response. The Western blot test is the confirmatory test used to verify a positive result from the ELISA. If the ELISA result is positive, the client should be informed that further testing, such as the Western blot, is needed to confirm the diagnosis of HIV infection. It is important to explain that the ELISA is a screening tool, and a positive result does not mean a definitive diagnosis without confirmation. This helps to set realistic expectations and ensures the client receives the appropriate follow-up care.

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Correct Answer is C

Explanation

A. "Early ambulation can help keep your lungs expanded and prevent pneumonia":
This statement is correct. Early ambulation is beneficial for respiratory function as it helps to keep the lungs expanded, encouraging deeper breaths and better oxygenation. This can help prevent complications like pneumonia and atelectasis, which are common after surgery due to immobility and anesthesia.

B. "Early ambulation is one part of preventing blood clots from forming in your legs":
This statement is also correct. Early ambulation is an important measure in preventing deep vein thrombosis (DVT) and pulmonary embolism (PE), which are common postoperative complications. Movement and walking promote circulation, reducing the risk of blood clots forming in the legs.

C. "Early ambulation usually delays wound healing and increases the risk of wound infection":
This statement is incorrect. Early ambulation does not delay wound healing or increase the risk of infection. In fact, early movement can help improve circulation, which is crucial for wound healing and tissue repair. Gentle movement and ambulation typically have positive effects on wound healing by promoting blood flow to the surgical site. However, patients should avoid excessive strain or stress on the wound to prevent dehiscence or other complications.

D. "Early ambulation can help your bladder and bowels recover from the anesthesia":
This statement is correct. Early ambulation helps stimulate gastrointestinal and urinary systems, which may be sluggish after anesthesia. Walking can encourage the return of normal bowel and bladder function by promoting peristalsis and helping to prevent constipation or urinary retention, both of which can be common after surgery.

A. Apply an ice pack for pain B. Loosen any constricting bandages or braces C. Document and continue to monitor D. Elevate the extremity

Correct Answer is B

Explanation

A) Apply an ice pack for pain:
While ice might help with pain and swelling in some cases, the client’s symptoms suggest a serious circulation problem, possibly compartment syndrome or vascular injury. These symptoms indicate the need for immediate intervention to restore blood flow, not just pain relief.

B) Loosen any constricting bandages or braces:
The client’s symptoms are highly suggestive of impaired circulation, which could be caused by compartment syndrome) or a vascular injury. Loosening any constricting bandages or braces is crucial to restoring circulation to the affected limb. Immediate action to relieve pressure is necessary to prevent permanent damage.

C) Document and continue to monitor:
Documenting and continuing to monitor without immediate action is inappropriate. The client’s symptoms represent a potential emergency, and delaying intervention could lead to irreversible damage to the limb. Immediate action is required to prevent complications like tissue necrosis or loss of limb function.

D) Elevate the extremity:
Elevating the extremity is not appropriate in this situation, as it may worsen circulation to the affected limb. Elevation could reduce venous return, further compromising blood flow to the area. Instead, immediate action to relieve pressure and improve circulation is the priority.

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A client is tested for human immunodeficiency virus (HIV) infection with an enzyme- linked immunosorbent assay (ELISA), and the test result & positive. What would the nurse tell the client?

Nursing Test Bank

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Explanation

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Explanation

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