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?
Give a complete bed bath to further assess the client.
Remove the fentanyl patch as directed by prescription.
Call for ambulance transportation to the hospital immediately.
Discuss end-of-life decisions with the client’s parents.
The Correct Answer is D
Answer and explanation The correct answer is D. Choice A rationale
Giving a complete bed bath to further assess the client may not be the most appropriate intervention in this case. The client is semi-conscious and cries out in pain when turned or moved. A complete bed bath could potentially cause unnecessary discomfort and distress.
Choice B rationale
Removing the fentanyl patch as directed by prescription may not be the best course of action. Fentanyl is a powerful opioid used to manage severe pain. The client’s parents report that their child cries out in pain when turned or moved, suggesting that the client is experiencing significant pain. Removing the fentanyl patch could potentially exacerbate the client’s pain.
Choice C rationale
Calling for ambulance transportation to the hospital immediately may not be necessary at this time. The client’s vital signs are stable, and there is no indication of an immediate medical emergency based on the information provided.
Choice D rationale
Discussing end-of-life decisions with the client’s parents is the most appropriate intervention. The client is semi-conscious, sleeps most of the time, and is in significant pain. These symptoms suggest that the client’s condition is deteriorating. It is important to have conversations about end-of-life care preferences and decisions to ensure that the client’s wishes are respected and that the parents are prepared.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Answer and explanation The correct answer is C. Choice A rationale
A hurricane that destroys 50,000 homes and kills 5,000 victims is a high-intensity disaster, but it is not small-scope. The impact is widespread, affecting a large number of homes and people.
Choice B rationale
A forest fire that destroys 25,000 acres and causes significant damage to livestock is also a high-intensity disaster. However, the scope is not small as it affects a large area and has a significant impact on the local economy.
Choice C rationale
A tornado that destroys 25 houses and uproots an interstate for 0.5 miles is an example of a high-intensity, small-scope disaster. The disaster is high-intensity due to the destructive nature of a tornado, but the scope is relatively small, affecting only a limited number of houses and a small section of an interstate.
Choice D rationale
An explosion at a water treatment plant that affects the community water supply is a high- intensity disaster due to the potential for widespread impact on the community’s water supply. However, the scope is not necessarily small as it could affect a large population.
Correct Answer is B
Explanation
Answer and explanation
The correct answer is Choice B.
Choice A rationale
A potassium level of 3.7 mEq/L (3.7 mmol/L) is within the normal range, which is typically between 3.6 and 5 mEq/L12. Therefore, this result does not need to be reported immediately to the healthcare provider.
Choice B rationale
B-type natriuretic peptide (BNP) levels are used to diagnose and monitor heart failure. A BNP level of 550 pg/mL (550 ng/L) is significantly higher than the normal range, which is less than 100 pg/mL34. High BNP levels indicate that the heart is working harder than normal, which is a common occurrence in heart failure. Therefore, this result should be reported immediately to the healthcare provider.
Choice C rationale
A total cholesterol level of 190 mg/dL (4.92 mmol/L) is considered borderline high. While it’s important to manage cholesterol levels in patients with heart failure, this result is not critical and does not need to be reported immediately to the healthcare provider.
Choice D rationale
A glycosylated hemoglobin (A1C) level of 7% is at the threshold for the diagnosis of diabetes. Diabetes can complicate the management of heart failure and increase the risk of cardiovascular events. However, this result is not critical and does not need to be reported immediately to the healthcare provider.
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