A nurse is assisting with the plan of care for10-month-old infant who has HIV. Which of the following interventions should the nurse include in the plan?
Administer granulocyte colony stimulating factor.
Monitor the infant's lymphocyte count.
Initiate droplet precautions.
Educate the infant's guardians about exchange transfusions.
The Correct Answer is B
A) Administer granulocyte colony stimulating factor: Granulocyte colony-stimulating factor (G-CSF) is used to stimulate white blood cell production in certain conditions like neutropenia. However, in an infant with HIV, the primary concern is the HIV progression and monitoring for complications rather than administering G-CSF. It is not routinely used for infants with HIV unless there is a specific indication such as neutropenia.
B) Monitor the infant's lymphocyte count: Monitoring the infant’s lymphocyte count is an appropriate and essential intervention. HIV affects the immune system by targeting CD4+ T lymphocytes, so tracking the lymphocyte count will help gauge the progression of the disease and the effectiveness of the treatment. It is vital to assess the infant’s immune status, as HIV can lead to a weakened immune system and increase susceptibility to infections.
C) Initiate droplet precautions: Droplet precautions are typically required for infections like influenza or certain respiratory illnesses. HIV is not transmitted via droplets; it is primarily transmitted through blood, sexual contact, and from mother to child during childbirth or breastfeeding. Therefore, droplet precautions are not necessary for this infant.
D) Educate the infant's guardians about exchange transfusions: Exchange transfusions are generally not a routine intervention for infants with HIV unless there is a specific complication like severe hyperbilirubinemia or other hematologic conditions. The focus for infants with HIV is on managing antiretroviral therapy (ART) and preventing infections, rather than performing exchange transfusions. Educating the guardians about ART and infection prevention would be more appropriate.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A) "What makes you believe that the science behind immunization is wrong?": This question may come across as confrontational and judgmental, which can potentially shut down communication. It could make the client feel defensive and less likely to engage in an open discussion about their concerns. The nurse should aim to create a non-judgmental and open dialogue to understand the client's perspective.
B) "Is not taking the immunization worth the risk of getting very sick during flu season?": This question is somewhat leading and may sound as if the nurse is trying to pressure the client into changing their mind. It could also create a sense of guilt or fear rather than fostering a cooperative conversation about the client's beliefs and concerns.
C) "Why are you opposed to receiving immunization?": While this question may seem straightforward, it is a bit too direct and could feel accusatory to the client. It might be better to approach the conversation in a way that invites the client to express their concerns without feeling challenged or defensive.
D) "What is your biggest concern with receiving immunization?": This is the most effective and open-ended question. It allows the client to express their concerns in a non-confrontational way. The nurse can then listen to the client's reasons, provide information, and address any misconceptions or fears the client may have, fostering a respectful and informative discussion.
Correct Answer is D
Explanation
A) Regresses to an earlier developmental level:
While it is possible for a child to show some regression in behavior when faced with a stressful situation such as a sibling’s illness, school-age children are typically able to understand more complex concepts. Regression to an earlier developmental stage is more common in younger children (preschool-age) rather than school-age children, who are more likely to express their emotions in other ways.
B) Alienates himself from his peers:
While the child may experience feelings of isolation or withdrawal due to the stress of a sibling’s terminal illness, alienation from peers is not the most typical or immediate response for a school-age child. It is more common for children of this age to seek comfort and support from peers, though they may struggle with how to discuss their feelings.
C) Believes that his brother's death will be reversible:
At a school-age level, children generally begin to understand the permanence of death. While younger children may have magical thinking that could lead them to believe the death of a loved one could be reversible, this is not the expected response for a school-age child. By this age, children typically comprehend that death is final, although they may struggle with the emotional aspect of it.
D) Believes his bad behavior is causing his brother's death:
This response is the most typical for a school-age child. At this stage, children often have a sense of responsibility for events around them and may develop feelings of guilt or magical thinking, where they believe their actions or behavior contributed to the illness or death of a loved one. This belief is part of the normal coping process but needs to be addressed in counseling or with support from caregivers to help the child understand the situation and alleviate any misplaced guilt.
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