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. Increased bowel sounds:

In end-of-life care, clients often experience a decrease in bowel sounds rather than an increase. Bowel sounds may diminish or become absent as the body's systems slow down.

B. Hypertension:

Hypertension is less commonly observed in clients at the end of life. Instead, blood pressure may decrease as the body's overall function declines.

C. Mottled skin:

Mottled skin, characterized by a blotchy or marbled appearance, is a common finding in clients approaching the end of life. It occurs due to changes in peripheral circulation and may indicate decreased perfusion.

D. Moist mucous membranes:

In contrast to moist mucous membranes, clients at the end of life may experience dry mucous membranes. Reduced oral intake and hydration levels can lead to dryness of the mouth and mucous membranes.

A. The child was brought to the facility 30 min after the injury occurred. B. The parents report that the child injured herself by falling off the couch. C. The child begins to cry when her arm is examined by the provider. D. The child's examination shows a single injury.

Correct Answer is B

Explanation

Explanation:

A. The child was brought to the facility 30 minutes after the injury occurred:

The timing of seeking medical attention alone may not necessarily indicate abuse. However, if there are inconsistencies in the reported mechanism of injury or if there is a delay in seeking medical care without a valid explanation, it can raise suspicion and warrant further investigation.

B. The parents report that the child injured herself by falling off the couch:

While falls are common causes of fractures in toddlers, spiral fractures are more commonly associated with twisting or torsional forces, which can raise concerns about non-accidental trauma. If the reported mechanism of injury does not align with the type of fracture or if there are inconsistencies in the history provided, it may indicate potential abuse.

C. The child begins to cry when her arm is examined by the provider:

It is common for children to cry or show discomfort during a physical examination, especially if they are in pain or feeling anxious. While this finding alone may not indicate abuse, it is essential to assess the child's behavior, pain response, and overall presentation for any additional signs or patterns of abuse.

D. The child's examination shows a single injury:

The presence of a single injury does not necessarily rule out abuse. Abusive injuries can be single or multiple, and the absence of other injuries does not negate the possibility of abuse. It is crucial to consider the context, history, and clinical findings comprehensively when evaluating for abuse.

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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 in a community clinic is caring for a 20-month-old toddler who has spiral fractures of the right ulna and radius. Which of the following findings should the nurse recognize as a potential indication of abuse?

Correct Answer is B

Explanation

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