The nurse is participating in a care planning conference for a patient with acquired immunodeficiency syndrome (AIDS). What is the nurse's highest priority in providing care to this client?
Instituting measures to prevent infection.
Providing emotional support.
Identifying risk factors related to contracting AIDS.
Discussing the cause of AIDS.
The Correct Answer is A
Choice A Reason: Instituting measures to prevent infection is the highest priority in providing care to this client, as AIDS impairs the immune system and makes the client susceptible to opportunistic infections that can be life-threatening.
Choice B Reason: Providing emotional support is an important aspect of providing care to this client, but it is not the highest priority, as it does not address the physical needs of the client.
Choice C Reason: Identifying risk factors related to contracting AIDS is not relevant for providing care to this client, as it does not help to improve the current condition or prevent complications.
Choice D Reason: Discussing the cause of AIDS is not essential for providing care to this client, as it does not affect the treatment or prognosis of the disease.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A Reason: Compressing the nares is not the first action that the nurse should take, as it may increase intracranial pressure and worsen the head injury.
Choice B Reason: Administering decongestant for postnasal drip is not the first action that the nurse should take, as it may mask the signs of cerebrospinal fluid (CSF) leakage and delay diagnosis and treatment.
Choice C Reason: Tilting the head back is not the first action that the nurse should take, as it may cause aspiration of CSF or blood and increase the risk of infection.
Choice D Reason: Collecting the drainage is the first action that the nurse should take, as it helps to identify if the drainage is CSF or nasal secretions, and to monitor the amount and characteristics of the drainage.
Correct Answer is D
Explanation
Choice A Reason: Impaired skin integrity is not the most appropriate nursing diagnosis for a client with Addison's disease, as it does not reflect the main problem of adrenal insufficiency and cortisol deficiency.
Choice B Reason: Fluid volume overload is not the most appropriate nursing diagnosis for a client with Addison's disease, as it does not reflect the main problem of adrenal insufficiency and aldosterone deficiency.
Choice C Reason: Imbalanced nutrition: more than body requirements is not the most appropriate nursing diagnosis for a client with Addison's disease, as it does not reflect the main problem of adrenal insufficiency and weight loss.
Choice D Reason: Risk for injury is the most appropriate nursing diagnosis for a client with Addison's disease, as it reflects the main problem of adrenal insufficiency and hypotension, which can cause falls, fainting, or shock.
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