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A nurse is caring for a client who is homeless. Which of the following actions should the nurse take first?
- A. Determine the client's understanding of her living situation
- B. Assist the client to develop goals for obtaining shelter
- C. Discuss the risks of being homeless with the client
- D. Develop client teaching using a variety of strategies
Correct Answer: A
Rationale: The correct answer is A: Determine the client's understanding of her living situation. This is the first step because it allows the nurse to assess the client's current situation and needs. Understanding the client's perspective is crucial for providing effective care and support. Assisting the client in developing goals (B) or discussing risks (C) should come after understanding the client's current situation. Developing client teaching (D) is important but should be based on the client's understanding and needs, which is why it comes after assessing their understanding.
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A home health nurse is caring for a client who has chemotherapy-induced nausea that has been resistant to relief from pharmacological measures. Which of the following interventions should the nurse initiate? (Select all that apply)
- A. Use seasonings to enhance the flavor of foods
- B. Provide sips of room temperature ginger ale between meals
- C. Maintain the head of the client's bed in an elevated position after eating
- D. Offer 120 ml (4 oz.) of cold 2% milk as a meal replacement
- E. Assist the client in using guided imagery
Correct Answer: B, C, E
Rationale: The correct interventions for the client with chemotherapy-induced nausea are B, C, and E.
B: Providing sips of room temperature ginger ale can help alleviate nausea due to its antiemetic properties.
C: Maintaining the head of the client's bed in an elevated position after eating can prevent acid reflux and reduce nausea.
E: Assisting the client in using guided imagery can help distract from nausea and promote relaxation.
Incorrect choices:
A: Using seasonings may exacerbate nausea in some clients.
D: Offering cold milk as a meal replacement may not be well-tolerated by a nauseated client and could worsen symptoms.
In summary, the correct interventions focus on soothing the stomach, promoting relaxation, and preventing exacerbation of nausea, while the incorrect choices may not directly address the client's symptoms or could potentially worsen them.
A faith community nurse is preparing to meet with the family of an adolescent who has leukemia. Which of the following actions should the nurse plan to take?
- A. Focus the discussion on the adolescent's future career plans.
- B. Determine how the adolescent's health has affected family roles.
- C. Ask another family from the same faith congregation to attend the meeting for support.
- D. Direct conversation to the parents to avoid embarrassing the adolescent.
Correct Answer: B
Rationale: The correct answer is B: Determine how the adolescent's health has affected family roles. This is important because the nurse needs to understand the impact of the adolescent's illness on the family dynamics and roles. By assessing this, the nurse can provide appropriate support and resources to help the family cope effectively.
Choice A is incorrect because focusing on the adolescent's future career plans may not address the immediate concerns and emotional needs of the family facing a health crisis.
Choice C is incorrect as involving another family may not be appropriate without the consent of the adolescent and their family.
Choice D is incorrect because directing the conversation solely to the parents may exclude the adolescent from being an active participant in their own care and may not address their unique needs.
A nurse working in an infectious disease clinic is caring for a client who has a new diagnosis of Lyme disease. Which of the following agencies is responsible for voluntarily reporting cases of this disease to the Centers for Disease Control and Prevention?
- A. Office of the Surgeon General
- B. State Department of Health
- C. Hospital infection control department
- D. Local Red Cross chapter
Correct Answer: B
Rationale: The correct answer is B: State Department of Health. The State Department of Health is responsible for voluntarily reporting cases of Lyme disease to the Centers for Disease Control and Prevention (CDC) because they are tasked with monitoring and controlling the spread of infectious diseases within their jurisdiction. They have the mandate to collect and report data on disease outbreaks to the CDC, enabling national surveillance and response efforts. The other choices are incorrect because the Office of the Surgeon General does not have direct jurisdiction over disease reporting, the hospital infection control department focuses on internal infection control measures, and the Local Red Cross chapter is primarily involved in disaster relief and blood services, not disease surveillance.
A nurse is counseling a client who is to undergo enzyme-linked immunosorbent assay (ELISA) testing for HIV. Which of the following information should the nurse include?
- A. The test monitors progression of the disease
- B. The test measures antibodies to the virus
- C. The test results are accurate 24 hr after exposure to the virus
- D. A positive result requires initiating immunoglobulin administration
Correct Answer: B
Rationale: The correct answer is B because ELISA testing for HIV measures antibodies to the virus, indicating exposure to the virus. This is crucial for diagnosing HIV infection. Choice A is incorrect because ELISA does not monitor disease progression. Choice C is incorrect as it takes weeks, not hours, for accurate results post-exposure. Choice D is incorrect as immunoglobulin administration is not the treatment for a positive HIV result.
A hospice nurse is talking with the partner of a client who is near death. The partner states, 'How will I go on without them? I already feel alone.' Which of the following actions should the nurse take?
- A. Express sympathy to the client's partner.
- B. Ask the client's partner if they need anything.
- C. Hug the client's partner.
- D. Reassure the client's partner that it will get better.
Correct Answer: A
Rationale: Correct Answer: A: Express sympathy to the client's partner.
Rationale: Expressing sympathy acknowledges the partner's emotions, validates their feelings, and shows empathy. It helps the partner feel heard and supported during a difficult time. This action focuses on the partner's emotional needs, offering comfort and understanding.
Summary:
B: Asking if the partner needs anything is helpful but may not address the emotional distress directly.
C: Hugging without consent may not be appropriate and could make the partner uncomfortable.
D: Reassuring without acknowledging the partner's feelings may come across as dismissive and invalidating.