This is the edited text:

A client has a new diagnosis of human immunodeficiency virus (HIV). The client is distraught and does not know what to do. What intervention by the nurse is best?

Assess the client’s support system

Call the hospital clergy to speak with the client.

Explain the legal requirement to tell sex partners

Offer to tell the family for the client

Answer and Explanation

The Correct Answer is A

Choice A reason: This is the best intervention because it helps the nurse to understand the client's emotional, social, and practical needs and resources. A new diagnosis of HIV can be a devastating and overwhelming experience for the client, who may face stigma, discrimination, isolation, or rejection from others. The nurse should assess the client's support system, such as family, friends, or community groups, that can provide comfort, guidance, and assistance to the client. The nurse should also encourage the client to seek professional counseling, peer support, or other services as needed.

Choice B reason: This is not the best intervention because it may not respect the client's preferences, beliefs, or values. The nurse should not assume that the client wants or needs spiritual or religious support, unless the client expresses such a desire. The nurse should ask the client about their spiritual or religious beliefs and practices and provide appropriate referrals or resources as requested by the client. The nurse should also respect the client's right to privacy and confidentiality and not disclose the client's diagnosis to anyone without the client's consent.

Choice C reason: This is not the best intervention because it may not be the most urgent or appropriate topic to discuss with the client at this time. The nurse should not focus on the legal or ethical aspects of the client's diagnosis, but rather on the client's emotional and physical wellbeing. The nurse should explain the legal requirement to tell sex partners in a sensitive and respectful manner, but only after the client has accepted and understood their diagnosis and has expressed readiness to disclose their status to others. The nurse should also provide the client with information and resources on how to prevent the transmission of HIV and how to protect themselves and their partners.

Choice D reason: This is not the best intervention because it may not be the client's wish or choice. The nurse should not offer to tell the family for the client, unless the client asks for such help. The nurse should respect the client's autonomy and decisionmaking regarding whom to tell and when to tell about their diagnosis. The nurse should also support the client in preparing for the possible reactions and outcomes of disclosing their status to their family and others.

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

Explanation

Choice A reason: A temperature of 101.3 degrees Fahrenheit is a sign of fever, which is a common symptom of infection. Clients with AIDS have a weakened immune system and are more susceptible to opportunistic infections. Fever indicates that the body is trying to fight off an infection.

Choice B reason: An oxygen saturation of 97% on room air is within the normal range and does not indicate infection. Oxygen saturation measures the percentage of hemoglobin that is bound to oxygen in the blood. A low oxygen saturation may indicate respiratory problems, such as pneumonia, which is a common infection in clients with AIDS.

Choice C reason: A respiratory rate of 22 breaths per minute is slightly above the normal range of 12 to 20 breaths per minute, but it does not necessarily indicate infection. Respiratory rate may vary depending on factors such as activity level, stress, pain, or anxiety. A high respiratory rate may indicate respiratory distress, which could be caused by infection or other conditions.

Choice D reason: Purulent drainage is a thick, yellowgreen, or brown pus that indicates infection. It may come from a wound, an abscess, or a body cavity. Purulent drainage is a sign of inflammation and infection and should be reported to the health care provider.

Choice E reason: A client's ability to ambulate 20 feet is not related to infection. Ambulation is a measure of mobility and function and may be affected by factors such as pain, fatigue, or muscle weakness. Ambulation does not reflect the presence or absence of infection.

A. The client is in a private room. B. The client has a dedicated vital signs machine. C. The client has a vase of fresh flowers on the table. D. There is hand sanitizer by the door.

Correct Answer is C

Explanation

Choice A reason: The client is in a private room is not an observation that requires further action by the nurse, because it is appropriate and desirable. The client with reduced immunity should be in a private room, as it can reduce the exposure to pathogens or allergens that may cause infection or inflammation. The client with reduced immunity has a weakened or impaired immune system, which makes them more susceptible and vulnerable to infection. The private room can also provide privacy, comfort, and security for the client.

Choice B reason: The client has a dedicated vital signs machine is not an observation that requires further action by the nurse, because it is appropriate and desirable. The client with reduced immunity should have a dedicated vital signs machine, as it can prevent the crosscontamination or transmission of pathogens or allergens that may cause infection or inflammation. The vital signs machine is a device that measures the blood pressure, pulse, temperature, and oxygen saturation of the client. The vital signs machine can be contaminated by the blood, body fluids, or secretions of the client or other clients, and can harbor bacteria, viruses, or fungi. The dedicated vital signs machine can also ensure the accuracy, consistency, and availability of the measurements for the client.

Choice C reason: The client has a vase of fresh flowers on the table is an observation that requires further action by the nurse, because it is inappropriate and undesirable. The client with reduced immunity should not have a vase of fresh flowers on the table, as it can increase the exposure to pathogens or allergens that may cause infection or inflammation. The fresh flowers are a source of mold, pollen, or insects, which can trigger allergic reactions, respiratory distress, or skin irritation. The fresh flowers can also contain bacteria, viruses, or fungi, which can infect the client through inhalation, ingestion, or contact. The vase of fresh flowers should be removed from the room and replaced with artificial flowers, pictures, or cards.

Choice D reason: There is hand sanitizer by the door is not an observation that requires further action by the nurse, because it is appropriate and desirable. The client with reduced immunity should have hand sanitizer by the door, as it can promote the hand hygiene and infection prevention of the client and others. Hand sanitizer is a product that contains alcohol or other agents that can kill or reduce the number of pathogens or allergens that may cause infection or inflammation. Hand sanitizer should be used by the client, the staff, and the visitors before and after entering or leaving the room, or after touching any objects or surfaces in the room.

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This is the edited text:A client has a new diagnosis of human immunodeficiency virus (HIV). The client is distraught and does not know what to do. What intervention by the nurse is best?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client has acquired immunodeficiency syndrome (AIDS). Which of these assessment findings indicate possible infection? (Select all that apply.)

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

Explanation

A nurse enters the hospital room of a client with reduced immunity. What observation requires further action by the nurse?

Correct Answer is C

Explanation

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This is the edited text:

A client has a new diagnosis of human immunodeficiency virus (HIV). The client is distraught and does not know what to do. What intervention by the nurse is best?