An older client comes to the clinic with a family member. When the nurse attempts to take the client's health history, the client does not respond to questions in a clear manner. Which action should the nurse implement first?

Provide a printed health care assessment form.

Defer the health history until the client is less anxious.

Ask the family member to answer the questions.

Assess the surroundings for noise and distractions.

Answer and Explanation

The Correct Answer is D

The ability to effectively communicate and provide accurate information can be impacted by external factors such as noise, distractions, or an unfamiliar environment. By assessing the surroundings, the nurse can identify and address any potential barriers to communication.

Once the nurse has addressed any environmental factors that may be hindering communication, they can proceed with other strategies to facilitate the health history assessment. This may include providing a printed healthcare assessment form to assist the client in organizing their thoughts or deferring the assessment until the client is less anxious.

Asking the family member to answer the questions should be considered if the client is unable to provide accurate information or is cognitively impaired. However, it is important to first address any environmental factors and attempt to engage the client directly in the assessment process.

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Correct Answer is A

Explanation

A) Correct- Zidovudine is an antiretroviral medication used in the treatment of HIV infection.

One of the potential side effects of zidovudine is hematological toxicity, including anemia (low red blood cell count) and neutropenia (low white blood cell count). The appearance of pinpoint, red, round spots on the skin could be indicative of petechiae, which are small hemorrhages caused by the leakage of blood into the skin. Petechiae can occur due to low platelet counts, a
component of the complete blood count (CBC). Monitoring the complete blood count is important for clients receiving zidovudine to identify any potential adverse effects on blood cell counts. Anemia and neutropenia can increase the risk of infection, bleeding, and other complications. Therefore, any changes in blood cell counts, including the presence of petechiae, should be reported to the healthcare provider for further evaluation and management.
B) Incorrect- This is used to assess allergic reactions and is not specifically related to the appearance of petechiae.
C) Incorrect- A skin biopsy is typically performed to diagnose skin conditions or diseases and is not the primary assessment to evaluate the cause of petechiae.
D) Incorrect- Electromyography is a diagnostic test used to assess muscle and nerve function and is not relevant to the appearance of petechiae associated with zidovudine use.

A. Tell the client to discuss the medication side effects with the healthcare provider. B. Tell the client that the medication's side effects will most likely dissipate over time. C. Inform the client that gradual tapering must be used to discontinue the medication. D. Remind the client that feeling better is the therapeutic effect of the medication.

Correct Answer is C

Explanation

The correct answer is choice c. Inform the client that gradual tapering must be used to discontinue the medication.

Choice A rationale:

While discussing medication side effects with the healthcare provider is important, it does not address the immediate concern of discontinuing the medication safely. The nurse should provide guidance on the proper discontinuation process.

Choice B rationale:

Telling the client that side effects will most likely dissipate over time may not be accurate for all individuals and does not address the client’s desire to stop the medication.

Choice C rationale:

Informing the client that gradual tapering must be used to discontinue the medication is crucial. Abruptly stopping antidepressants can lead to withdrawal symptoms and a potential relapse of depression.

Choice D rationale:

Reminding the client that feeling better is the therapeutic effect of the medication is true, but it does not address the client’s concern about discontinuing the medication safely.

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An older client comes to the clinic with a family member. When the nurse attempts to take the client's health history, the client does not respond to questions in a clear manner. Which action should the nurse implement first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client who is receiving zidovudine reports the appearance of pinpoint, red, round spots on the skin. Which result should the nurse report to the healthcare provider?

Correct Answer is A

Explanation

Correct Answer is C

Explanation

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