A client who was a victim of a rape and was confirmed HIV positive six months ago arrives at the clinic for an appointment.

The client is thin, with a saddened affect and talks about frequently crying and feeling hopeless.

The client describes not wanting to see anyone or go out of the house.

Which action should the nurse take?

Explain the ELISA test will be needed to confirm the results.

Identify support systems in the client's life.

Inquire about plans to further education.

Explore feelings of hope for the future.

Inquire about plans to further education.

Answer and Explanation

The Correct Answer is B

Choice A rationale

Explaining the ELISA test for confirmation is unnecessary as the client is already confirmed HIV positive. Repeating the test may cause confusion and anxiety without offering additional benefit at this stage.

Choice B rationale

Identifying support systems in the client's life is crucial for addressing the emotional and psychological impact of being HIV positive and a victim of rape. Support systems, such as family, friends, or support groups, can provide the necessary emotional support and practical assistance to help the client cope with the challenges.

Choice C rationale

Inquiring about plans to further education may not be timely or appropriate in the context of the client's current emotional state. The priority should be addressing the client's immediate mental health needs and ensuring they have adequate support systems in place.

Choice D rationale

Exploring feelings of hope for the future is important but may not be the immediate priority. The client is currently experiencing significant emotional distress, so addressing their immediate mental health needs and ensuring support is a higher priority.

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Correct Answer is B

Explanation

Choice A rationale

Disagreeing with the client's delusions and setting clear limits on talking about it may cause the client to become defensive and anxious, worsening the situation.

Choice B rationale

Presenting a personal perception of reality in a nonconfrontational manner helps the client feel understood and supported while gently guiding them back to reality. It is an effective approach to managing delusions.

Choice C rationale

Agreeing with the client's delusions and asking open-ended questions reinforces the delusional thinking and may not be helpful in the long term.

Choice D rationale

Immediately informing the healthcare provider about the delusional episode may be necessary if the delusions pose a risk, but it does not provide immediate support to the client.

A. Document the wound measurements with tunneling. B. Cleanse the wound and discontinue the VAC system. C. Increase the wound VAC suction to eliminate the drainage. D. Consult the wound care specialist to evaluate the wound. E. Reapply the VAC system after irrigating away drainage.

Correct Answer is ["A","B","D"]

Explanation

Choice A rationale

Documenting the wound measurements with tunneling is important for tracking the wound's progression and planning appropriate interventions. Accurate documentation helps in assessing the effectiveness of the treatment plan.

Choice B rationale

Cleansing the wound and discontinuing the VAC system is necessary when foul, purulent drainage is observed. This action helps to prevent further infection and allows the healthcare provider to reassess the wound care approach.

Choice D rationale

Consulting the wound care specialist to evaluate the wound is essential for expert advice on managing complex wounds. Specialists can provide tailored recommendations to promote wound healing and prevent complications.

Choice C rationale

Increasing the wound VAC suction to eliminate the drainage is not appropriate as it may worsen the infection or damage the surrounding tissues. Proper wound care protocols should be followed to ensure safe and effective treatment.

Choice E rationale

Reapplying the VAC system after irrigating away drainage is not advisable if there is evidence of infection. The wound should be thoroughly assessed, and appropriate measures should be taken to address the underlying infection.

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Naxlex Comprehensive Predictor Exams

The nurse is caring for a client who has a history of experiencing delusions. The client describes singing in a concert in the afternoon for thousands of people. Which action should the nurse take?

Correct Answer is B

Explanation

When changing the client's dressing for a vacuum-assisted closure (VAC) wound therapy system, the nurse observes foul, purulent drainage. Which intervention(s) should the nurse implement? Select all that apply.

Correct Answer is ["A","B","D"]

Explanation

Exhibits The nurse is reviewing the client's data. Which of the following findings should the nurse report to the primary health care provider immediately? Select all that apply.

The healthcare provider (HCP) prescribes 0.99% normal saline 500 mL IV bolus to be infused over 30 minutes. How many mL/hour should the nurse set the infusion pump? (Enter numerical value only) .

After the nurse witnesses a preoperative client signing the surgical consent form, the nurse signs the form as a witness. Which is the legal implication of the nurse's signature on the client's surgical consent form? Select all that apply.

The healthcare provider prescribes a 5% dextrose injection with 20 units of regular insulin for a client with a serum potassium level of 6.0 mEq/L (6.0 mmol/L) and glucose level of 180 mg/dL (10.0 mmol/L). Which evaluation is most important for the nurse to include in this client's plan of care?

The psychiatric nurse is talking to a newly admitted client when another male client, who is diagnosed with antisocial behavior, intrudes on the conversation and tells the nurse, "I have to talk to you right now! It is very important!" How should the nurse respond to this client?

The nurse is managing the care for a client with hyperparathyroidism and is reviewing the client's list of prescribed and over-the-counter medications. Which medication(s) on the client's current medication record should the nurse discuss further with the healthcare provider? Select all that apply.

A nurse is monitoring a client receiving a blood transfusion. Which of the following actions should the nurse take first?