The home health nurse visits a young adult client who has AIDS with Kaposi’s sarcoma and peripheral neuropathies. The client’s parents, who are the caretakers, tell the nurse that their child sleeps most of the time.
The nurse assesses that the client is semi-conscious with stable vital signs, cries out in pain when turned or moved, has a fentanyl patch in place, and skin lesions that are closed and dried.
Which intervention should the nurse implement?

Answer and explanation

The correct answer is Choice A.

Choice A rationale

If an older adult client reports pain, redness, and swelling in the eye, asking about discharge from the eye is crucial. These symptoms could indicate a number of conditions, including conjunctivitis or uveitis. Discharge, especially if it is pus-like or sticky, could suggest an infection.

Choice B rationale

While keeping immunizations up-to-date is generally important for health, it is not the most relevant question in this context. Not all eye conditions are preventable through immunization.

Choice C rationale

Asking about new medications is relevant as certain medications can cause side effects or allergic reactions that affect the eyes. However, the symptoms described are more commonly associated with conditions like conjunctivitis or uveitis, which are not typically caused by medications.

Choice D rationale

Regular hand washing is important for general health and can prevent the spread of many diseases. However, it is not the most relevant question when a client presents with pain, redness, and swelling in the eye.

Answer and explanation The correct answer is D. Choice A rationale

While the discussion of food exchanges and calories being well-attended indicates interest and engagement in the class, it does not necessarily reflect an improvement in the clients’ management of their diabetes.

Choice B rationale

Parking convenience for attendees, while important for accessibility and attendance, does not provide information about the effectiveness of the classes in improving diabetes management.

Choice C rationale

Demonstrating the use of a blood glucose meter can be an effective teaching strategy, but it does not provide measurable outcomes related to the clients’ diabetes control.

Choice D rationale

Fasting blood glucose average readings being 20% lower at the end of the classes is a direct and measurable outcome that indicates improved diabetes control. This suggests that the classes were effective in teaching clients how to better manage their type 2 diabetes.