A patient diagnosed with HIV-II is admitted to the hospital presenting symptoms of fever, night sweats, and a severe cough.
The laboratory results show a CD4+ cell count of 180/mm and a negative tuberculosis (TB) skin test conducted 4 days prior.
What is the first action the nurse should take?
Inform the primary health care provider about the CD4+ results.
Implement Airborne Precautions for the patient.
Initiate Droplet Precautions for the patient.
Provide care using Standard Precautions.
The Correct Answer is D
Rationale for Choice A:
While it's important for the primary healthcare provider to be informed about the CD4+ results, it's not the first action the nurse should take. The priority is to implement appropriate infection control measures to protect the patient, other patients, and healthcare staff.
CD4+ cell count is a crucial indicator of the patient's immune status. A count of 180/mm is significantly low, suggesting a weakened immune system and increased vulnerability to infections. However, informing the provider alone doesn't directly address the immediate need for infection control.
Rationale for Choice B:
Airborne Precautions are specifically used for patients with known or suspected airborne infections, such as tuberculosis, measles, or varicella. These precautions involve the use of negative pressure rooms and N95 respirators.
In this case, the patient's TB skin test was negative, indicating no evidence of active tuberculosis infection. Implementing Airborne Precautions unnecessarily could lead to excessive resource utilization and potential stigmatization of the patient.
Rationale for Choice C:
Droplet Precautions are used for patients with infections that can be spread through large respiratory droplets, such as influenza, pertussis, or meningococcal meningitis. These precautions involve the use of masks and eye protection.
While the patient's symptoms of fever, night sweats, and severe cough could be consistent with a droplet-spread infection, there's no definitive evidence to support this at the present time. Initiating Droplet Precautions without a clear indication could also lead to unnecessary resource use and potential anxiety for the patient.
Rationale for Choice D:
Standard Precautions are the foundation of infection control and should be used for all patients, regardless of their known or suspected infection status. These precautions include hand hygiene, use of personal protective equipment (PPE) when indicated, and safe handling of sharps and bodily fluids.
By implementing Standard Precautions, the nurse can effectively minimize the risk of transmission of pathogens, protecting both the patient and other individuals in the healthcare setting. This is the most appropriate first action to ensure a safe and appropriate level of care.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale:
While providing information about post-operative care and pain management is important, it may not directly address the patient's underlying anxiety or encourage them to express their concerns.
It could be perceived as dismissive of their feelings or as an attempt to control the conversation. It focuses on the future rather than the patient's present experience.
Choice B rationale:
This response, while intended to be reassuring, may minimize the patient's individual experience and feelings. It could make the patient feel as though their concerns are not being taken seriously.
It implies that anxiety is a normal and expected reaction, which may discourage the patient from sharing their specific worries.
Choice C rationale:
This response is open-ended and invites the patient to share their thoughts and feelings.
It demonstrates active listening and encourages the patient to take an active role in the conversation.
It allows the nurse to assess the patient's understanding of the surgery and to address any misconceptions or concerns. It conveys a sense of empathy and understanding, which can help to build trust and rapport with the patient.
Choice D rationale:
While offering to explain the procedure may be helpful, it may not be what the patient needs at the moment. It could overwhelm the patient with information, particularly if they are already feeling anxious.
It could shift the focus away from the patient's emotional needs and onto the technical aspects of the surgery.
Correct Answer is A
Explanation
Choice A rationale:
It is crucial to prioritize the patient's spouse's emotional needs and preferences during this highly stressful and sensitive situation. Offering the choice to be present during resuscitation demonstrates respect for their autonomy, promotes family- centered care, and facilitates coping mechanisms.
Key considerations supporting this approach:
Respect for Autonomy:
Patients and their loved ones have the right to make informed decisions about their care, including being present during resuscitation efforts.
Respecting this right fosters trust, empowers the spouse, and aligns with ethical principles of patient autonomy. Family-Centered Care:
Family-centered care recognizes the importance of family members in the patient's care and decision-making.
Inviting the spouse to be present demonstrates a commitment to including them in the care process and supporting their emotional needs.
Facilitating Coping Mechanisms:
Witnessing resuscitation efforts can be distressing, but it can also provide closure, acceptance, and the opportunity to say goodbye.
Some individuals find comfort in being present and actively involved, even in difficult circumstances. The nurse can provide emotional support and guidance throughout the process.
Potential Benefits of Presence:
Studies have shown that family presence during resuscitation can have positive outcomes, such as decreased anxiety and post- traumatic stress disorder (PTSD) symptoms in family members.
It may also contribute to greater satisfaction with care and a sense of peace for those who choose to be present.
Rationales for other choices:
Choice B: Requesting that the spouse sit in the waiting room may isolate them and increase their anxiety. It deprives them of the opportunity to be involved in decision-making and potentially delays their grieving process.
Choice C: While the hospital's crisis team can provide valuable support, immediate referral may not align with the spouse's immediate needs or preferences. It's essential to first assess their emotional state and offer the choice of being present.
Choice D: Suggesting prayer may be appropriate for some individuals, but it should not be the first or only option presented. It's important to respect the spouse's spiritual beliefs and offer a range of support options.
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