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 B

Explanation

Explanation:

A. Glasgow coma scale result - This would be included in the assessment segment of SBAR, as it provides a clinical evaluation of the client's current neurological status.

B. History of the injury - The situation segment is used to briefly explain the current situation or the reason for the report. Including the history of the injury provides context about why the client is receiving care.

C. Medication during the next shift - This information is part of the Recommendation segment of SBAR. The nurse should include any upcoming medication administration, changes in medication orders, or specific medications that need to be administered during the next shift.

D. Intracranial pressure readings - This information should be included in the Assessment segment of SBAR. It provides important data about the client's intracranial status, helps monitor for changes or trends, and guides ongoing management and interventions.

A. Place the head of the client's bed flat. B. Perform nasotracheal suctioning for the client. C. Increase the heat in the client's room, D. Administer an opioid narcotic to the client.

Correct Answer is D

Explanation

Explanation:

A. Place the head of the client's bed flat:

This action is not appropriate because lying flat can worsen dyspnea in many cases. It can restrict lung expansion and make breathing more difficult. Instead, the nurse should elevate the head of the bed or position the client in a semi-Fowler's or high-Fowler's position to facilitate easier breathing.

B. Perform nasotracheal suctioning for the client:

Nasotracheal suctioning is not indicated for dyspnea unless there is a specific medical reason, such as airway obstruction or excessive secretions. Performing suctioning without a clear indication can cause discomfort and may not address the underlying cause of dyspnea.

C. Increase the heat in the client's room:

Adjusting the room temperature is generally not a direct intervention for dyspnea. While maintaining a comfortable environment is important, dyspnea is usually managed through other means such as medication and positioning.

D. Administer an opioid narcotic to the client:

This is the most appropriate action among the choices provided. Opioid narcotics, such as morphine, are commonly used to alleviate dyspnea in end-of-life care. They help reduce the sensation of breathlessness, calm respiratory distress, and improve overall comfort for the client.

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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 giving change-of-shift report using the SBAR technique about a client who has a traumatic brain injury. When reporting information about the client, which of the following should the nurse include in the situation segment of SBAR?

Correct Answer is B

Explanation

A nurse is caring for a client who is at the end of life and is experiencing dyspnea. Which of the following actions should the nurse take?

Correct Answer is D

Explanation

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