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A client with acquired immune deficiency syndrome and esophagitis due to Candida fungus is scheduled for an endoscopy. What actions by the nurse are most appropriate? (Select all that apply.)
- A. Assess the client's mouth and throat.
- B. Determine if the client has a stiff neck.
- C. Ensure that the consent form is on the chart.
- D. Maintain NPO status as prescribed.
- E. Percuss the client's abdomen.
Correct Answer: A,C,D
Rationale: Oral Candida fungal infections can lead to esophagitis. This is diagnosed with an endoscopy and biopsy. The nurse assesses the client's mouth and throat beforehand, ensures valid consent is on the chart, and maintains the client in NPO status as prescribed. A stiff neck and abdominal percussion are not related to this diagnostic procedure.
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A client has just been diagnosed with human immune deficiency virus (HIV). The client is distraught and does not know what to do. What action by the nurse is best?
- A. Assess the client for support systems.
- B. Determine if a clergy member would help.
- C. Provide detailed information about HIV treatment.
- D. Offer to tell the family for the client.
Correct Answer: A
Rationale: This client needs the assistance of support systems. The nurse should help the client identify them and what role they can play in supporting him or her. A clergy member may or may not be welcome. Providing detailed information may be overwhelming at this stage, and the client may not want the family to know.
A nurse works on a unit that has admitted its first client with acquired immune deficiency syndrome. The nurse overhears staff members talking about the 'AIDS guy' and wondering how the client contracted the disease. What action by the nurse is best?
- A. Confront the staff members about unethical behavior.
- B. Ignore the behavior to avoid confrontation.
- C. Report the behavior to the unit's nursing management.
- D. Tell the client that other staff members are talking about him or her.
Correct Answer: A
Rationale: The professional nurse should be able to confront unethical behavior assertively. The staff should not be talking about clients unless they have a need to do so for client care. Ignoring the behavior may be more comfortable, but the nurse is abdicating responsibility. The behavior may need to be reported, but not as a first step. Telling the client that others are talking about him or her does not accomplish anything.
A client with acquired immune deficiency syndrome has oral thrush and difficulty eating. What actions does the nurse delegate to the unlicensed assistive personnel (UAP)? (Select all that apply.)
- A. Apply oral anesthetic gels before meals.
- B. Assist with oral care.
- C. Offer the client frequent sips of cool drinks.
- D. Provide the client with alcohol-based mouthwash.
- E. Remind the client to use only a soft toothbrush.
Correct Answer: B,C,E
Rationale: The UAP can assist with oral care, offer fluids, and remind the client of things the nurse (or other professional) has already taught. Applying medications is performed by the nurse. Alcohol-based mouthwashes are harsh and drying and should not be used.
A client has a primary selective immunoglobulin A deficiency. The nurse should prepare the client for self-management by teaching what principle of medical management?
- A. Infusions will be scheduled every 3 to 4 weeks.
- B. Treatment is aimed at treating specific infections.
- C. Unfortunately, there is no effective treatment.
- D. You will need many immunoglobulin A infusions.
Correct Answer: B
Rationale: Treatment for this disorder is vigorous management of infection, not infusion of exogenous immunoglobulins. The other responses are inaccurate.
A client with acquired immune deficiency syndrome is in the hospital with severe diarrhea. What actions does the nurse delegate to the unlicensed assistive personnel (UAP)? (Select all that apply.)
- A. Assessing the client's fluid and electrolyte status.
- B. Assisting the client to use a soft toothbrush.
- C. Obtaining a bedside commode if the client is weak.
- D. Providing gentle perineal cleansing after stools.
- E. Reporting any abnormal patient status.
Correct Answer: B,C,D,E
Rationale: The UAP can assist the client with getting out of bed, obtain a bedside commode for the client's use, cleanse the client's perineal area after bowel movements, and report any abnormal observations such as redness or open areas. The nurse assesses fluid and electrolyte status.