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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 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.
During a home health visit, a school-age child who has muscular dystrophy confides in the nurse that he was struck by his parents. Which of the following actions should the nurse take first?
- A. Report the incident to local authorities.
- B. Check the child for injuries.
- C. Refer the parent to a social service agency.
- D. Enroll the parent in anger management classes.
Correct Answer: A
Rationale: The correct answer is A: Report the incident to local authorities. The first priority in this situation is to ensure the safety and well-being of the child. By reporting the incident to local authorities, the nurse can initiate a formal investigation to protect the child from further harm. Checking for injuries (B) is important but secondary to ensuring the child's safety. Referring the parent to a social service agency (C) may be appropriate but not the first step in cases of suspected abuse. Enrolling the parent in anger management classes (D) is not the immediate priority when a child is at risk of harm.
A nurse is discussing short- and long-term goals with a client who has alcohol use disorder and is being admitted to a treatment facility. Which of the following statements is appropriate for the nurse to include in the discussion?
- A. You will be taking a once-weekly dose of disulfiram to help control withdrawal symptoms during treatment
- B. Remaining physically active will help to minimize drowsiness and chills associated with initial alcohol withdrawal
- C. Attending Al-Anon meetings will help you identify a role model to assist you with making needed changes
- D. You will begin learning functional skills to replace defense mechanisms and behaviors while in treatment
Correct Answer: D
Rationale: Correct Answer: D: You will begin learning functional skills to replace defense mechanisms and behaviors while in treatment
Rationale: This statement is appropriate because it focuses on the core aspect of treatment for alcohol use disorder, which is addressing maladaptive coping mechanisms with healthier alternatives. By learning functional skills to replace defense mechanisms and behaviors, the client can develop healthier coping strategies and decrease the likelihood of relapse in the long term.
Summary of other choices:
A: Incorrect - Disulfiram is not used to control withdrawal symptoms; it is a deterrent medication to discourage alcohol consumption.
B: Incorrect - Physical activity is beneficial, but it does not directly address the underlying issues of alcohol use disorder.
C: Incorrect - Al-Anon meetings are for family and friends of individuals with substance use disorders, not for the individual seeking treatment.
E, F, G: No information provided.
A home health nurse is scheduled for a first-time visit to a client. Which of the following should the nurse perform first?
- A. Blood pressure screening
- B. Mental status examination
- C. Review of the neighborhood
- D. Family history
Correct Answer: C
Rationale: The correct answer is C: Review of the neighborhood. This should be performed first to assess the safety and environment of the client's home, ensuring the nurse's safety and the ability to provide care effectively. It helps identify potential hazards or resources in the community. Blood pressure screening (A) can wait until after ensuring a safe environment. Mental status examination (B) is important but can be conducted after assessing the neighborhood. Family history (D) is not a priority for the first visit.
A home health nurse manager is caring for a client who has methicillin-resistant Staphylococcus aureus. Which of the following actions should the nurse take?
- A. Remove fresh flowers from the client's home
- B. Wear a mask when within 3 feet of the client
- C. Encourage the client to use a HEPA filter in the house
- D. Double bag soiled dressing in polyethylene bags
Correct Answer: D
Rationale: The correct answer is D: Double bag soiled dressing in polyethylene bags. This is important to prevent the spread of methicillin-resistant Staphylococcus aureus (MRSA) to others. Double bagging the soiled dressing in polyethylene bags helps contain the bacteria and reduces the risk of transmission.
Choice A: Removing fresh flowers is not directly related to preventing the spread of MRSA.
Choice B: Wearing a mask within 3 feet of the client may not be effective in preventing MRSA transmission.
Choice C: Using a HEPA filter is not specifically targeted at preventing MRSA transmission.
In summary, choice D is correct because it directly addresses the prevention of MRSA transmission, while the other choices are not as directly related to this specific concern.