Which of the following statements made by a client diagnosed with human immunodefiency virus (HIV) would require further teaching?

Correct Answer: D

Rationale: The correct answer is D, "I will only need to take HIV medications for 6 months, and I will be cured." This statement would require further teaching because there is currently no cure for HIV, and lifelong medication adherence is essential for managing the virus. Option A, "I will have to be careful and avoid crowds," is correct as individuals with HIV have weakened immune systems and need to avoid exposure to infections in crowded places. Option B, "I will take prescribed medications," is also correct as medication adherence is crucial for controlling HIV and preventing disease progression. Option C, "I will have to take medications for the rest of my life," is the most appropriate statement as HIV is a chronic condition that requires lifelong treatment to manage the virus effectively. Educationally, it is important to emphasize to clients with HIV the importance of lifelong medication adherence, regular medical follow-ups, and a healthy lifestyle to maintain their health and well-being. Providing accurate information and dispelling misconceptions about HIV treatment is crucial in empowering individuals to manage their condition effectively.

Correct Answer: D

Rationale: In this scenario, the correct action for the nurse to take when a client on bed rest complains of pain and burning in the right calf area is to compare the circumference to the left calf (Option D). The rationale behind choosing this action is based on the suspicion of deep vein thrombosis (DVT) in the right calf. Comparing the circumference of the right calf to the left calf can help in identifying unilateral swelling, which is a common sign of DVT. This assessment is crucial in detecting a potential life-threatening condition early and initiating prompt treatment. Option A, deeply palpating the area for rebound tenderness, is incorrect because rebound tenderness is not a relevant assessment in this context and could potentially cause harm by dislodging a clot if DVT is present. Option B, medicating the client for pain and reassessing in 60 minutes, delays the assessment and treatment of a possible DVT, which can lead to serious complications like pulmonary embolism. Option C, percussing over the area for a change in tone, is not the appropriate assessment for evaluating calf pain and burning in this case. In an educational context, understanding the rationale behind choosing the correct action not only reinforces clinical knowledge but also emphasizes the importance of thorough assessment skills in nursing practice. Recognizing the signs and symptoms of DVT and knowing the appropriate actions to take can significantly impact patient outcomes and safety.

Correct Answer: C

Rationale: In the context of systemic lupus erythematosus (SLE), the appropriate nursing intervention for a client would be to administer topical hydrocortisone (Option C). This is because SLE is an autoimmune disease that causes inflammation in various parts of the body, and corticosteroids like hydrocortisone help to reduce this inflammation and manage the symptoms of SLE. Option A, intense cold therapy to the extremities, is not appropriate for SLE as cold therapy can potentially exacerbate symptoms in individuals with autoimmune conditions by triggering inflammation and vasoconstriction. Option B, encouraging ultraviolet (UV) light exposure, is also not recommended for SLE patients as UV light can exacerbate skin symptoms and trigger flares in individuals with photosensitive lupus. Option D, administering antibiotics, is not the correct intervention for SLE as it is an autoimmune condition and not caused by a bacterial infection. Administering antibiotics would not address the underlying autoimmune response seen in SLE. Understanding these interventions in the context of SLE is crucial for nurses to provide effective care for patients with this condition. It is important for nurses to be knowledgeable about appropriate interventions to manage symptoms and improve the quality of life for individuals living with SLE.

Correct Answer: A

Rationale: In caring for an immobile client, the priority assessment is the auscultation of lung sounds (Option A). This is crucial because immobility can lead to respiratory complications such as pneumonia, atelectasis, or respiratory infections. By assessing lung sounds, the nurse can detect any abnormalities early and intervene promptly to prevent further complications. Assessment of skin turgor (Option B) is important for evaluating hydration status but is not the priority in an immobile client as respiratory issues pose a more immediate threat to health. Auscultation of bowel sounds (Option C) and assessment for peripheral edema (Option D) are also important assessments but do not take precedence over assessing the respiratory status in an immobile client. In an educational context, understanding the priority assessments for immobile clients is essential for providing quality care and preventing complications. Nurses need to prioritize assessments based on the client's condition to ensure timely interventions and promote positive outcomes.

Correct Answer: D

Rationale: The correct answer is D) Stage 2. This wound assessment describes a stage 2 pressure ulcer, which is characterized by a shallow, open ulcer with a reddened base but no slough. In stage 2, the damage extends through the epidermis and into the dermis, presenting as a partial-thickness loss of skin. This stage requires appropriate wound care and monitoring to prevent further complications. Option A) Stage 3 is incorrect because in stage 3, the ulcer extends into the subcutaneous tissue, presenting as a full-thickness wound with possible slough but not through muscle or bone. Option B) Stage 4 is incorrect as stage 4 ulcers involve full-thickness skin loss with extensive tissue damage, potentially reaching muscle or bone. Option C) Stage 1 is incorrect because in stage 1, the skin is intact but may show non-blanchable redness, indicating a risk of pressure injury but not a full ulcer. Understanding wound staging is crucial for nurses to provide appropriate care, prevent complications, and promote healing. Nurses must accurately assess and document wounds to guide treatment decisions and prevent progression to more severe stages. Knowledge of wound staging also helps in communicating effectively with the healthcare team and ensuring consistent care practices.