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
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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Related Questions
Correct Answer is D
Explanation
Explanation:
A. "I promise I won't tell anyone about this."
This statement is not appropriate because nurses are mandated reporters of suspected child abuse. Promising confidentiality in cases of abuse goes against legal and ethical responsibilities. The nurse must report suspected abuse to the appropriate authorities for the safety and well-being of the child.
B. "Your family is bad for doing this to you."
This statement is judgmental and may make the child feel guilty or conflicted about their family. It is essential to avoid blaming or shaming language when addressing a child who has been abused. The focus should be on providing support, validation, and appropriate intervention.
C. "Let's discuss what you have told me with your family members."
This statement is not appropriate because it suggests involving the family members in the discussion of abuse, which can potentially put the child at risk of further harm. It's essential to prioritize the safety of the child and follow appropriate reporting procedures rather than involving potentially abusive family members in discussions about abuse.
D. "It is not your fault that this happened."
This statement is appropriate and supportive. It reassures the child that they are not to blame for the abuse they have experienced. It acknowledges the child's feelings and helps them understand that they are not responsible for the actions of the abuser. This statement can provide comfort and validation to the child during a difficult time.
Correct Answer is B
Explanation
Explanation:
A. Avoid touching the client:
While it's essential to be gentle and respectful when touching an unresponsive client, avoiding all touch may not be appropriate. Touch can be a comforting and reassuring gesture, and many clients at the end of life benefit from gentle touch, such as holding their hand or providing a gentle massage.
B. Continue to talk to the client as if they are awake:
Talking to the client, even if they are unresponsive, is encouraged. Hearing is often the last sense to diminish, and talking to the client in a soothing and reassuring manner can provide comfort and a sense of presence. The nurse should speak calmly and compassionately, addressing the client by name and providing updates on care activities.
C. Limit the client's visitors to one at a time:
Limiting the number of visitors and controlling the environment can help maintain a calm and peaceful atmosphere for the client. However, the specific number of visitors allowed at a time may vary based on the client's preferences, cultural considerations, and facility policies. It's important to respect the client's wishes regarding visitors while ensuring their comfort and well-being.
D. Whisper when talking in the client's room:
Whispering may not be necessary unless the client is particularly sensitive to loud noises. Speaking in a calm and gentle tone is generally more appropriate, as it allows the client to hear clearly without causing unnecessary strain or confusion.
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