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?

Choice A rationale:
Tolerance to the opiate medication is developing. This is the most likely explanation for why the client's pain is no longer being controlled by the same dose of medication. Tolerance is a physiological adaptation that occurs with repeated exposure to opioids, leading to a decrease in their effectiveness over time. This means that the client's body is becoming less responsive to the medication, and a higher dose is needed to achieve the same level of pain relief.
Choice B rationale:
There is likely a history of addiction. While it is possible that the client has a history of addiction, this is not the most likely explanation for why the medication is no longer controlling the pain. Addiction is a complex condition that is characterized by compulsive drug seeking and use, despite negative consequences. It is not simply a matter of tolerance developing.
Choice C rationale:
The client is opiate naive. This means that the client has not previously been exposed to opioids. While opiate-naive clients may be more sensitive to the effects of opioids, they are also more likely to experience side effects, such as nausea and vomiting. The fact that the client has been receiving the same dose of medication for 2 days without experiencing side effects suggests that they are not opiate naive.
Choice D rationale:
Physical dependence. Physical dependence is a state of adaptation that occurs with repeated exposure to opioids, leading to withdrawal symptoms if the medication is abruptly stopped. However, physical dependence does not necessarily mean that the medication is no longer effective in controlling pain.

Choice A rationale:
While a young patient who lives alone may need some assistance with post-discharge care, they have nearby family and friends who can likely provide this support. This patient's situation does not present the same level of complexity and risk as the other patients described in the options.
The presence of nearby family and friends can offer practical and emotional support, helping with tasks such as transportation, meal preparation, and medication management. This social support network can play a crucial role in ensuring a smooth transition from the hospital to home.
Additionally, the patient's young age suggests a higher likelihood of physical and cognitive abilities that can facilitate self-care and adherence to discharge instructions.
Choice B rationale:
The older adult who lives alone and has memory loss has the greatest need for the nurse to consult with other members of the healthcare team regarding post-discharge care. This patient's situation presents several significant challenges that necessitate a collaborative approach to ensure safety and well-being:
Memory loss: The patient's memory loss may impair their ability to follow discharge instructions, manage medications, and maintain personal safety. This raises concerns about potential medication errors, missed appointments, and risks of falls or accidents.
Living alone: The patient's lack of immediate support at home further compounds these risks. Without someone to provide reminders, assistance with tasks, or monitoring for changes in health status, the patient's vulnerability increases.
Potential for social isolation: Living alone with memory loss can also lead to social isolation, which can negatively impact mental and physical health.
Choice C rationale:
While a married young adult who is the primary caregiver for children may face challenges in balancing their own recovery with caregiving responsibilities, they have a spouse who can provide support and assistance. This patient's situation does not present the same degree of risk as the older adult with memory loss living alone.
Choice D rationale:
The middle-aged patient who has undergone knee replacement and requires physical therapy will need support and guidance, but their needs are primarily focused on physical rehabilitation and pain management. These needs can often be addressed through standard discharge planning and coordination with physical therapy services.