Which of the following statements by a client with human immunodeficiency virus (HIV) does NOT requires further teaching?

Correct Answer: C

Rationale: The correct answer is option C: "I need to ensure that I place my needles in a proper needle disposal container." This statement does not require further teaching because it demonstrates the client's understanding of the importance of proper needle disposal to prevent the spread of infections. Option A is incorrect because HIV is not typically spread through contact with surfaces, so wearing gloves in public for this reason is unnecessary and indicates a misunderstanding of how the virus is transmitted. Option B is incorrect because having HIV does not automatically mean the person has developed AIDS. HIV is the virus that can lead to AIDS, but not all individuals with HIV progress to the AIDS stage. Option D is incorrect because having unprotected intercourse when one partner has HIV can lead to the transmission of the virus to the partner who does not have HIV. It is crucial for individuals with HIV to practice safe sex to prevent the spread of the virus. In an educational context, this question highlights the importance of providing accurate information and dispelling misconceptions about HIV. It emphasizes the need for clear communication and education to ensure that individuals with HIV understand how to prevent the transmission of the virus and protect themselves and others.

Correct Answer: B

Rationale: In the context of caring for a client with osteoarthritis, the goal of medication therapy is to reduce pain and inflammation (Option B). Osteoarthritis is a chronic condition characterized by joint pain and inflammation, and medications are used to help manage these symptoms to improve the individual's quality of life. Option A, eradicating the disease, is not possible as osteoarthritis is a degenerative condition that cannot be cured completely with current medical treatments. Option C, turning on the immune system, is incorrect because osteoarthritis is not an autoimmune condition where immune system activation would be beneficial. Option D, managing weight loss, while important for overall health and can help reduce strain on joints, is not the primary goal of medication therapy for osteoarthritis. Educationally, understanding the goals of medication therapy in osteoarthritis helps nurses provide effective care to clients with this condition. By addressing pain and inflammation, medications can help improve mobility, decrease disability, and enhance the client's ability to engage in daily activities. This knowledge is essential for providing holistic care and promoting the well-being of individuals with osteoarthritis.

Correct Answer: D

Rationale: In this scenario, the correct answer is option D, the older adult with a hip fracture who is immobile, as they are at the highest risk for skin breakdown. The rationale behind this is that immobility can lead to prolonged pressure on certain areas of the body, increasing the likelihood of developing pressure ulcers. Older adults have thinner, more fragile skin and decreased blood flow, further predisposing them to skin breakdown. Option A, the adolescent with a patella fracture in an immobilizer, is at risk but typically has better skin integrity due to younger age and more robust circulation. Option B, the young adult with a femur fracture going to surgery soon, is not immobile for an extended period, reducing the risk of skin breakdown. Option C, the middle-aged adult with a fractured radius and a cast, is also at risk but less so than the immobile older adult. Educationally, this question highlights the importance of recognizing risk factors for skin breakdown, especially in immobile patients. Nurses must prioritize preventative measures such as regular repositioning, skin assessments, and moisture management to mitigate the risk of pressure ulcers in such high-risk individuals.

Correct Answer: A

Rationale: In this scenario, the nurse's priority action for a client with compromised immunity is option A) Wash hands before entering the client's room. This is the correct answer because proper hand hygiene is crucial in preventing the transmission of infections, especially to individuals with compromised immunity who are more susceptible to infections. By washing hands before entering the client's room, the nurse reduces the risk of introducing harmful pathogens to the client, thus promoting their safety and well-being. Option B) Take the client's vital signs every 4 hours is not the priority action in this case. While monitoring vital signs is essential in patient care, ensuring proper hand hygiene to prevent infections takes precedence, particularly for a client with compromised immunity. Option C) Determine whether it is temporary or permanent is not the priority action as well. While understanding the nature of the client's compromised immunity is important for long-term care planning, immediate infection prevention through hand hygiene is more critical in ensuring the client's safety. Option D) Teach the family members to receive the flu shot annually is not the priority action either. While educating family members about preventive measures is beneficial for the client's overall health, the immediate need to prevent infections through hand hygiene is more pressing in this case. In an educational context, understanding the rationale behind the priority actions in caring for clients with compromised immunity is vital for nursing practice. Emphasizing the significance of infection control measures, such as hand hygiene, not only protects the clients but also helps instill a culture of patient safety among healthcare providers. By prioritizing actions that directly address the immediate risk to the client's health, nurses can effectively promote positive outcomes and quality care delivery.

Correct Answer: B

Rationale: In systemic sclerosis (scleroderma), Raynaud's phenomenon is often the first symptom to occur. Raynaud's phenomenon involves the narrowing of blood vessels in response to cold or stress, leading to reduced blood flow to extremities like fingers and toes, causing them to turn white or blue. This symptom is characteristic of scleroderma's vascular component. Tachycardia (option A) is not typically the first symptom of scleroderma. While heart involvement can occur, it usually presents later in the disease progression. Joint pain (option D) may occur in some cases but is not typically the initial symptom. Intense wrinkle (option C) is not a recognized early symptom of scleroderma. In an educational context, understanding the typical progression of symptoms in systemic sclerosis is crucial for healthcare professionals to recognize and diagnose the condition promptly. Educating students and practitioners on the hallmark signs and symptoms of scleroderma can lead to early intervention and improved outcomes for patients.