A community health nurse is evaluating eligibility for home assistance for a client who is quadriplegic. Which of the following actions should the nurse perform first?
Determine the client's living situation.
Problem solve with the client.
Offer community resources to the client.
Assist the client with decision-making
The Correct Answer is A
A. Determine the client's living situation: Assessing the client’s home environment is the first step in evaluating eligibility for home assistance. Understanding factors such as accessibility, caregiver support, and safety needs provides a foundation for planning appropriate interventions and resources tailored to the client’s circumstances.
B. Problem solve with the client: Problem-solving is an important part of care planning but should occur after the nurse has gathered essential information about the client’s living situation. Without this initial assessment, problem-solving may not address the client’s actual needs.
C. Offer community resources to the client: Providing information about resources is helpful but premature without first understanding the client’s living conditions and specific support requirements. This ensures recommendations are relevant and actionable.
D. Assist the client with decision-making: Supporting decision-making is crucial for client-centered care but comes after the nurse has assessed the client’s situation and presented appropriate options. Initial assessment informs safe and effective guidance.
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Related Questions
Correct Answer is C
Explanation
A. Rupture the amniotic sac: Artificial rupture of membranes is contraindicated in complete placenta previa because it can trigger severe maternal hemorrhage due to placental location over the cervical os.
B. Medicate the client for pain: While pain management may be necessary, the immediate priority is maternal and fetal safety. Pain control does not address the life-threatening risk of bleeding with placenta previa.
C. Prepare the client for a cesarean section: Complete placenta previa requires delivery by cesarean section to prevent catastrophic hemorrhage. Preparing for surgery is the priority intervention for both maternal and fetal safety.
D. Perform a vaginal exam: Vaginal examination is contraindicated in complete placenta previa because it can disrupt the placenta and cause severe bleeding. It should not be performed.
Correct Answer is A
Explanation
A. Tetany: Calcium is essential for proper neuromuscular function. A deficiency can lead to increased neuromuscular excitability, resulting in muscle spasms, cramps, and tetany, which are hallmark signs of hypocalcemia.
B. Anemia: Anemia is typically related to deficiencies in iron, vitamin B12, or folate, not calcium. While calcium plays roles in other body functions, it is not a direct factor in hemoglobin synthesis or red blood cell production.
C. Kidney stones: Kidney stones are more commonly associated with hypercalcemia or high calcium excretion rather than calcium deficiency. Low calcium intake may actually increase oxalate absorption, but it is not a direct cause of stones.
D. Osteoarthritis: Osteoarthritis is a degenerative joint disease influenced by age, joint stress, and cartilage wear. Calcium deficiency affects bone density (leading to osteoporosis) rather than the cartilage degeneration seen in osteoarthritis.
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