A nurse is contributing to the plan of care for a client who has had HIV for 10 years and is at the end of life. Which of the following interventions should the nurse recommend?

Encourage the client to increase participation in community social activities

Prepare the client to begin highly active antiretroviral therapy (HAART)

Provide routine analgesia to minimize episodes of breakthrough pain

Promote client weight gain of one to two pounds per week

Answer and Explanation

The Correct Answer is C

Explanation:

A. Encourage the client to increase participation in community social activities:

While social activities can be beneficial for overall well-being, including mental and emotional aspects, at the end of life for a client with HIV, the focus shifts towards palliative care and symptom management. Encouraging social activities may not directly address the client's immediate end-of-life needs.

B. Prepare the client to begin highly active antiretroviral therapy (HAART):

Starting or continuing highly active antiretroviral therapy (HAART) may not be appropriate at the end of life. HAART is typically used to manage HIV infection and prolong life expectancy by controlling viral replication. However, at the end of life, the focus shifts towards comfort care rather than aggressive treatment aimed at extending life.

C. Provide routine analgesia to minimize episodes of breakthrough pain:

This intervention is more aligned with the principles of end-of-life care. Providing routine analgesia helps manage pain effectively, which is crucial for improving the client's comfort and quality of life during this stage.

D. Promote client weight gain of one to two pounds per week:

Weight gain may not be a priority at the end of life, especially if the client is experiencing advanced HIV disease or complications. Instead of focusing on weight gain, the emphasis should be on optimizing comfort, managing symptoms, and enhancing quality of life.

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Correct Answer is C

Explanation

Explanation:

A. Moist mucous membranes - This is unlikely in an end-of-life scenario. As death approaches, mucous membranes often become dry due to decreased fluid intake and decreased body function.

B. Tachycardia - Tachycardia, or a rapid heart rate, can be a common finding as death nears. It can result from various factors such as dehydration, fever, pain, or the body's response to stress.

C. Irregular respirations - Irregular respirations, including periods of apnea or agonal breathing (gasping, irregular, or shallow breaths), are typical findings in the end-of-life stage. These irregularities are part of the body's natural process as it shuts down.

D. Hypertension - Hypertension is less common in the end-of-life phase. Typically, blood pressure decreases as the body's systems begin to fail.

A. "The client has developed drooping facial features." B. "The client may benefit from a neurology consult." C. "The client is disoriented and pupils are slow to respond to light." D. "The client has a history of hypertension."

Correct Answer is D

Explanation

Explanation:

A. "The client has developed drooping facial features."

This statement provides specific information about a recent change in the client's condition, which is relevant background information. It helps the provider understand one of the key reasons for the communication.

B. "The client may benefit from a neurology consult."

While suggesting a neurology consult is a potential recommendation (R) in the SBAR tool, it is not part of the Background (B) component. Background information typically focuses on factual data about the client's history, current condition, and pertinent details relevant to the situation.

C. "The client is disoriented and pupils are slow to respond to light."

Similar to option B, this statement describes the client's assessment findings and current condition rather than providing background information. It would be more appropriate in the Assessment (A) component of the SBAR tool.

D. "The client has a history of hypertension."

This statement provides relevant background information about the client's medical history, specifically their history of hypertension. Including this information in the Background component helps the provider understand the client's baseline health status, which is important for evaluating the current situation.

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A nurse is contributing to the plan of care for a client who has had HIV for 10 years and is at the end of life. Which of the following interventions should the nurse recommend?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is collecting data from a client who is at the end of life. Which of the following findings should the nurse expect?

Correct Answer is C

Explanation

A nurse is caring for a client who has hypertension and recently developed drooping facial features. When contacting the provider, which of the following statements should the nurse include as part of the background component of the SBAR communication tool?

Correct Answer is D

Explanation

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