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A client states, 'My life has no meaning right now.' What is the nurse's best response?
- A. Have you been thinking about harming yourself?
- B. How long have you been feeling this way?
- C. Tell me what is going on with you right now.
- D. Do you really think your life has no purpose?
Correct Answer: A
Rationale: The correct answer is A. By asking the client if they have been thinking about harming themselves, the nurse is directly addressing the potential risk of suicide, which is crucial when a client expresses feelings of hopelessness. This question helps assess the client's safety and determine the need for immediate intervention. Choices B, C, and D are not as direct in addressing the potential risk of self-harm and may not provide the necessary urgency in ensuring the client's safety. Asking about self-harm is critical in assessing the severity of the client's distress and ensuring appropriate interventions are implemented promptly.
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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.
A community health nurse is working with a family that is struggling to adapt following the loss of a family member. Which of the following actions should the nurse take first?
- A. Refer the family to a grief support group.
- B. Determine the roles of individual family members.
- C. Encourage the family to assign specific tasks to individual family members.
- D. Assist the family to establish a daily routine.
Correct Answer: B
Rationale: The correct answer is B: Determine the roles of individual family members. This is the first step because understanding the roles within the family will help identify strengths and resources to support them through the grieving process. By determining roles, the nurse can assess each family member's needs and abilities, facilitating targeted interventions. Referral to a grief support group (A) may be beneficial later, but understanding family dynamics comes first. While assigning tasks (C) and establishing a routine (D) are important, they should come after identifying roles to ensure they are tailored to the family's specific needs.
A nurse is planning a program about healthy eating at an elementary school where most students select French fries and pizza at lunch every day. Which of the following actions should the nurse plan to take first?
- A. Give positive feedback to students who make appropriate choices.
- B. Help students recognize the value of making healthy food choices.
- C. Provide students with resources about making wise choices independently.
- D. Determine students' motivation to learn about healthy food choices.
Correct Answer: D
Rationale: The correct answer is D: Determine students' motivation to learn about healthy food choices. This is the first step because understanding the students' motivation will help tailor the program effectively. By assessing their motivation, the nurse can identify potential barriers to making healthy choices and address them in the program. Positive feedback (A) and resources (C) are important but should come after understanding motivation. Helping students recognize the value of healthy choices (B) is crucial, but motivation assessment precedes this step.
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 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.