A nurse is teaching a client who has AIDS and wishes to continue self-care at home despite living alone. Which of the following actions by the nurse demonstrates client advocacy?
Instruct the client to avoid eating raw vegetables.
Initiate a referral for the client to a home health agency.
Remind the client of the importance of medication adherence.
Tell the client to avoid places where there are large crowds of people.
The Correct Answer is B
Choice A reason: Instructing the client to avoid eating raw vegetables may be a precautionary measure due to potential immunosuppression from AIDS, but it does not directly demonstrate advocacy. Advocacy would involve actions that support the client's rights, choices, and interests, and while dietary advice is important, it is not an advocacy action in itself.
Choice B reason: Initiating a referral for the client to a home health agency is a clear demonstration of client advocacy. This action shows that the nurse is taking steps to ensure the client receives the necessary support to manage their condition at home, respecting their wish to maintain independence and quality of life.
Choice C reason: Reminding the client of the importance of medication adherence is part of the nurse's educational role but does not necessarily reflect advocacy. Advocacy would involve more proactive measures to support the client's treatment and care decisions.
Choice D reason: Telling the client to avoid places where there are large crowds of people is good advice to reduce the risk of infections, but it is not an advocacy action. Advocacy involves representing the client's interests and facilitating their choices and access to care.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A reason: Cheyne-Stokes respirations, characterized by a pattern of irregular breathing with periods of apnea, can be a sign of brain stem compression due to increased intracranial pressure. However, it is not typically the first sign of deteriorating neurological status.
Choice B reason: Pupillary dilation, especially if it is unilateral, can indicate pressure on the cranial nerves due to increased intracranial pressure. It is a concerning sign but may not be the first to appear as neurological function deteriorates.
Choice C reason: An altered level of consciousness is often the first sign of deteriorating neurological status in a patient with increased intracranial pressure. Changes in consciousness can range from slight disorientation or confusion to complete unresponsiveness.
Choice D reason: Decorticate posturing, which involves abnormal flexion of the arms with extension of the legs, indicates significant brain injury and is a later sign of increased intracranial pressure, not typically the first sign.
Correct Answer is D
Explanation
Choice A reason : Changing the transparent membrane dressing daily is not necessary unless it's soiled or compromised. The dressing is typically changed every 7 days or per institutional policy to reduce the risk of infection.
Choice B reason: Using a non-coring needle is not applicable for PICC lines as they are designed for use with a luer-lock syringe for medication administration and flushing.
Choice C reason : Maintaining a continuous IV infusion is not required for a PICC line unless clinically indicated. Intermittent use is common for medication administration, and the line should be flushed before and after use to maintain patency.
Choice D reason : Flushing the catheter with a 0.9% sodium chloride solution after each use is the correct action. This helps to maintain catheter patency and prevent occlusion.
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