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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 nurse is planning a priority intervention to reduce obesity in the community. Which of the following actions should the nurse take?
- A. Encourage enrollment and attendance at weight reduction programs
- B. Educate children at a daycare center about nutrition and exercise
- C. Distribute health risk appraisal questionnaires at community functions
- D. Measure the BMI of older adults at a community senior center
Correct Answer: B
Rationale: The correct answer is B: Educate children at a daycare center about nutrition and exercise. This is the priority intervention because educating children about nutrition and exercise can help prevent obesity in the long term. By teaching healthy habits early on, the nurse can make a significant impact on reducing obesity rates in the community. Encouraging enrollment in weight reduction programs (A) may help individuals who are already obese but does not address prevention. Distributing health risk appraisal questionnaires (C) and measuring BMI of older adults (D) are important but not the priority for reducing obesity in the community.
A nurse is working in a shelter following a disaster. Which of the following is the priority action for the nurse to take?
- A. Create diversionary activities for children
- B. Address the physical needs of clients
- C. Help clients gather needed supplies
- D. Explore feelings the clients are experiencing
Correct Answer: B
Rationale: The correct answer is B: Address the physical needs of clients. This is the priority action because in a disaster setting, ensuring the basic physical needs of clients such as food, water, shelter, and medical care takes precedence to ensure their survival and well-being. Without addressing these needs first, the clients' health and safety could be compromised. Creating diversionary activities for children (A), helping clients gather supplies (C), and exploring clients' feelings (D) are important but secondary to addressing immediate physical needs. It is crucial to prioritize basic survival needs before addressing emotional or social needs in a disaster situation.
A 35-year-old client who has a diagnosis of tuberculosis informs the provider's office that she is unable to pay for the treatment. Which of the following actions by the nurse will facilitate obtaining appropriate treatment?
- A. Help the client apply for Medicare
- B. Explore options for alternative therapies
- C. Arrange for medication through local agencies
- D. Send the client to the nearest facility for further evaluation
Correct Answer: C
Rationale: The correct answer is C: Arrange for medication through local agencies. This option addresses the immediate need for treatment by connecting the client with resources that can provide medication for tuberculosis at little to no cost. This ensures that the client can access appropriate treatment despite financial constraints.
Option A (Help the client apply for Medicare) may not be feasible or timely, as the client may not qualify or the application process may take too long. Option B (Explore options for alternative therapies) is not appropriate for a serious infectious disease like tuberculosis that requires specific medical treatment. Option D (Send the client to the nearest facility for further evaluation) does not address the client's inability to pay for treatment and may delay necessary intervention.
A nurse is assessing a client with hyperemesis gravidarum. Which of the following findings should the nurse expect?
- A. Oliguria
- B. Diplopia
- C. Hypoglycemia
- D. Dizziness
Correct Answer: A
Rationale: The correct answer is A: Oliguria. Hyperemesis gravidarum is severe nausea and vomiting during pregnancy, leading to dehydration and electrolyte imbalances. Oliguria, decreased urine output, is expected due to dehydration. Diplopia (B) and dizziness (D) are not specific to hyperemesis gravidarum. Hypoglycemia (C) may occur due to poor oral intake but is not a defining feature.
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.