During the first trimester of pregnancy, a client who was treated for genital herpes with acyclovir prior to this pregnancy tells the practical nurse (PN) that she is experiencing an episode of genital herpes. Which nursing intervention has the highest priority?

Assess her feelings about therapeutic abortions in the event the infant has been affected.

Identify current sexual partners so that they can be evaluated and treated for genital herpes if necessary.

Instruct her to avoid sexual intercourse while active, visible lesions are present.

Determine if the client has taken acyclovir for this outbreak of genital herpes.

Answer and Explanation

The Correct Answer is C

A.   Assess her feelings about therapeutic abortions in the event the infant has been affected. - While important to consider potential outcomes, immediate care involves preventing transmission and managing the current outbreak.
B.   Identify current sexual partners so that they can be evaluated and treated for genital herpes if necessary. - Contact tracing is important but not the highest priority in managing the current outbreak.
C.   Instruct her to avoid sexual intercourse while active, visible lesions are present. - This is crucial to prevent transmission of the herpes virus to the sexual partner and to reduce the risk of complications for the pregnancy.
D.   Determine if the client has taken acyclovir for this outbreak of genital herpes. - While important for understanding the treatment history, instructing the client on preventive measures has a higher priority.

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Correct Answer is ["A","B","D"]

Explanation

A. Measure head circumference daily. - Monitoring head circumference is crucial to detect changes that might indicate increased intracranial pressure after the shunt placement.
B. Document strict intake and output. - Monitoring fluid intake and output helps assess the infant's hydration status and shunt functionality.
C. Irrigate shunt and pump valve every 12-hours. - Shunt irrigation should be performed by specialized healthcare professionals, not typically by a practical nurse.
D. Monitor body temperature every 4 hours. - Postoperative monitoring includes assessing for signs of infection or systemic changes, which might be indicated by changes in body temperature.
E. Place in Trendelenburg position. - The Trendelenburg position is not typically recommended post-ventriculoperitoneal shunt placement and should be avoided unless specifically prescribed by the healthcare provider.

A. Try not to listen to the conversation since it is confidential. B. Write an incident report and submit it to the unit manager. C. Approach the individuals involved and ask them to stop. D. Tell the client of the UAP's concern for him.

Correct Answer is C

Explanation

A. Trying not to listen to the conversation does not address the issue of confidentiality breach or protect the client's privacy.
B. Writing an incident report might be necessary, but the immediate action should be to stop the conversation to protect the client's confidentiality.
C. Approaching the individuals involved and asking them to stop is the most appropriate and immediate action to protect the client's privacy and confidentiality.
D. Telling the client about the UAP's concern might not be suitable without context or proper consent, and it might not address the confidentiality breach.

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During the first trimester of pregnancy, a client who was treated for genital herpes with acyclovir prior to this pregnancy tells the practical nurse (PN) that she is experiencing an episode of genital herpes. Which nursing intervention has the highest priority?

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Naxlex Comprehensive Predictor Exams

A 2-day-old infant with hydrocephalus returns from surgery following placement of a ventriculoperitoneal shunt. Which nursing intervention(s) should the practical nurse (PN) implement during postoperative care? (Select all that apply.)

Correct Answer is ["A","B","D"]

Explanation

The practical nurse (PN) overhears a conversation between an unlicensed assistive personnel (UAP) and another staff member in the hospital cafeteria line concerning a client's reaction to being given a diagnosis of terminal cancer. What is the best nursing action?

Correct Answer is C

Explanation

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