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A home health nurse is planning the initial home visit for a client who has dementia and lives with his adult son's family. Which of the following actions should the nurse take first during the visit?
- A. Encourage the family to join a support group
- B. Provide the family with information about respite care
- C. Educate the family regarding the progression of dementia
- D. Engage the family in informal conversation
Correct Answer: D
Rationale: The correct answer is D: Engage the family in informal conversation. This is the first action the nurse should take during the initial visit because building rapport and establishing trust with the family is crucial in the care of a client with dementia. By engaging in informal conversation, the nurse can observe family dynamics, assess the family's understanding of the client's condition, and gather valuable information about the client's daily routine and needs. This lays the foundation for effective communication and collaboration moving forward.
A: Encouraging the family to join a support group can be beneficial but should come after establishing rapport and assessing the family's needs.
B: Providing information about respite care is important, but it is not the priority during the initial visit.
C: Educating the family about the progression of dementia is important, but it should be done after building rapport and assessing their current understanding.
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A nurse is caring for a client who is unconscious. Which of the following actions should the nurse take when providing oral care for the client?
- A. Test for the presence of the client's gag reflex
- B. Place the client in the supine position
- C. Use a firm toothbrush for tooth and gum care
- D. Use 2 gauze-wrapped fingers to hold the mouth open
Correct Answer: A
Rationale: The correct answer is A: Test for the presence of the client's gag reflex. This is important to prevent aspiration during oral care. By testing the gag reflex, the nurse can ensure the client's airway is protected. Placing the client in the supine position (choice B) can increase the risk of aspiration. Using a firm toothbrush (choice C) can damage the delicate tissues in the mouth. Using 2 gauze-wrapped fingers to hold the mouth open (choice D) can increase the risk of injury to the client's oral mucosa.
A nurse manager in a local community health agency is creating a job description for a new nurse who will practice community-oriented nursing. Which of the following should the nurse include in the job description? (Select all that apply)
- A. Investigate potential health and environmental issues
- B. Initiate support groups for parents of autistic children
- C. Provide wound care for clients in their homes
- D. Participate in local health surveillance activities
- E. Provide health-related education to community groups
Correct Answer: A,B,D,E
Rationale: The correct answer includes choices A, B, D, and E. Choice A is essential as investigating potential health and environmental issues is crucial in community-oriented nursing to identify and address health concerns. Choice B is important as initiating support groups for parents of autistic children promotes community well-being. Choice D is necessary as participating in local health surveillance activities helps in monitoring community health trends. Choice E is crucial as providing health-related education to community groups promotes health awareness and prevention. Choices C, F, and G are incorrect as they do not directly align with the scope of community-oriented nursing, which focuses on population-based care and health promotion rather than individual wound care or unspecified activities.
A school nurse is implementing health screening. Which of the following assessment findings should the nurse recognize as the highest priority?
- A. A child who has a BMI of 18
- B. An adolescent who has scoliosis
- C. An adolescent who has psoriasis
- D. A child who has nits
Correct Answer: B
Rationale: The correct answer is B: An adolescent who has scoliosis. Scoliosis is a spinal deformity that can progress and cause serious health issues if left untreated. The school nurse should prioritize this assessment finding to ensure early detection and appropriate interventions to prevent further complications. A: A child with a BMI of 18 may indicate underweight but is not as urgent as scoliosis. C: Psoriasis is a skin condition that may require management but is not immediately life-threatening. D: Nits (lice eggs) are a common issue but do not pose a significant health risk compared to scoliosis.
A community health nurse is working with a group of clients. The nurse practices the ethical principle of distributive justice by performing which of the following tasks?
- A. Keeping a promise to visit a client who is housebound after the delivery of care.
- B. Ensuring that a client who is homeless receives preventive medical care.
- C. Being honest with the parents of a child about the need to report suspected abuse.
- D. Accepting the decision of an older adult client to live alone in her home.
Correct Answer: B
Rationale: The correct answer is B. Distributive justice refers to fair distribution of resources and services to all individuals, with priority given to those in need. By ensuring that a homeless client receives preventive medical care, the nurse is upholding this principle. This action promotes equity and fairness by addressing the health needs of a vulnerable population.
A: Keeping a promise to visit a housebound client is important for maintaining trust and continuity of care, but it does not directly relate to distributive justice.
C: Being honest about reporting suspected abuse is related to ethical duty and integrity, not distributive justice.
D: Accepting an older adult's decision to live alone respects autonomy and independence, but it is not directly tied to distributive justice.
A parish nurse is counseling a family following a client's recent diagnosis of heart disease. Which of the following actions should the nurse take first?
- A. Discuss the benefits of eating a well-balanced diet with the client's family
- B. Assist the client and the client's partner with finding an affordable exercise program
- C. Offer to accompany the client and the client's partner during health care provider visits
- D. Ask family members about the impact of the disease on relationships within the family
Correct Answer: D
Rationale: The correct answer is D: Ask family members about the impact of the disease on relationships within the family. This is the first action the nurse should take because understanding the family dynamics and relationships can provide valuable insight into how the diagnosis is affecting everyone involved. By assessing the impact on relationships, the nurse can better tailor interventions to support the entire family unit and address any emotional or communication challenges that may arise.
Option A is incorrect as discussing diet benefits should come after assessing the family dynamics. Option B is incorrect because addressing exercise programs should also come after understanding the family's needs. Option C is incorrect as accompanying to provider visits is important but not the first priority.