A nurse is assisting with the plan of care for a 10-month-old infant who has HIV. Which of the following interventions should the nurse include in the plan?

Monitor the infant's lymphocyte count.

Educate the infant's guardians about exchange transfusions.

Administer granulocyte colony-stimulating factor.

Initiate droplet precautions.

Answer and Explanation

The Correct Answer is A

Monitoring the infant's lymphocyte count is important in evaluating the immune function of the infant. HIV primarily affects the immune system, including lymphocytes. Monitoring the lymphocyte count helps assess the progression of the disease and the effectiveness of treatment.

Exchange transfusions are not typically used in the management of HIV. They are primarily performed in conditions like severe neonatal jaundice or blood disorders, but not for the treatment of HIV.

Granulocyte colony-stimulating factor (G-CSF) is a medication used to stimulate the production of white blood cells called granulocytes. While G-CSF can be used in certain situations, such as to counteract the side effects of certain chemotherapy drugs, it is not a standard treatment for HIV in infants.

Droplet precautions are typically implemented for infectious diseases that spread through respiratory droplets, such as influenza or respiratory syncytial virus (RSV). HIV does not spread through respiratory droplets, so initiating droplet precautions would not be necessary in the care of an infant with HIV.

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Correct Answer is D

Explanation

This response acknowledges the son's exhaustion and offers a constructive solution by suggesting respite care. Respite care provides temporary relief to caregivers by arranging for someone else to take over caregiving responsibilities for a specific period of time.

It allows caregivers to have a break and take care of their own physical and emotional well-being. By providing information about respite care, the nurse is offering support and resources to help alleviate the son's fatigue while ensuring that the mother's care needs are still met.

A. Increase protein in the diet. B. Increase the client's fluids to 4 L per day. C. Encourage the client to have continual bed rest. D. Encourage strength-training exercise.

Correct Answer is A

Explanation

A. Protein supports tissue repair, maintains muscle mass, and provides sustained energy. Leukemia and its treatments can lead to muscle wasting and general weakness, so additional protein can help counteract these effects and improve energy levels. It is also essential for immune support as well.

B.Increasing fluids to 4 L per day is generally excessive and may not be appropriate for this client. Excessive fluid intake can place strain on the cardiovascular system, which could be problematic, especially if the client is receiving chemotherapy or other treatments that may impact fluid balance.

C.Continual bed rest is not recommended, as it can contribute to deconditioning, muscle atrophy, and worsening fatigue over time. While rest periods are essential for clients experiencing fatigue, it is equally important to incorporate balanced, low-intensity activity to maintain strength and circulation.

D.Such exercises require significant energy and exertion, which might not be tolerable and could exacerbate fatigue. Instead, gentle, low-impact activities like walking or stretching are more appropriate for maintaining function without overwhelming the client’s energy reserves.

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A nurse is assisting with the plan of care for a 10-month-old infant who has HIV. Which of the following interventions should the nurse include in the plan?

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