A community health nurse is performing a home health admissions assessment with a client. The client reports being unable to obtain their prescriptions. Which of the following actions should the nurse take first?

Notify the client's family member regarding their inability to obtain prescriptions.

Call the local pharmacist on behalf of the client.

Assess the barriers to the client's ability to obtain prescriptions.

Initiate a referral to a social worker.

Answer and Explanation

The Correct Answer is C

Rationale:
A. Notify the client’s family member regarding their inability to obtain prescriptions: Involving family members can be helpful later, but the nurse must first understand why the client cannot obtain medications before deciding whether family assistance is necessary.

B. Call the local pharmacist on behalf of the client: Contacting the pharmacist may help resolve access issues such as refills or delivery, but this step is premature without identifying the specific barriers that prevent the client from getting medications.

C. Assess the barriers to the client’s ability to obtain prescriptions: The first action is assessment to determine the root cause of the problem. Barriers may include lack of transportation, financial hardship, limited mobility, or misunderstanding of the prescription process. Once the cause is identified, appropriate interventions or referrals can be made.

D. Initiate a referral to a social worker: A social worker can assist with financial or community resources, but the nurse should first gather assessment data to provide accurate information for an effective referral.

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Correct Answer is B

Explanation

Rationale:
A. A financial power of attorney manages financial affairs, not medical decisions. Health care decisions are instead guided by a health care proxy or durable power of attorney for health care, as outlined in the client’s advance directives.

B. The Patient Self-Determination Act upholds the client’s autonomy by allowing them to accept or refuse medical or life-sustaining treatment. This includes the right to decline care, even if such refusal may lead to death, ensuring that personal values and wishes guide end-of-life care.

C. Advance directives can be revised or revoked by the client at any time, regardless of notarization, as long as the client remains mentally competent. The document reflects current wishes and is not legally binding indefinitely.

D. Family members cannot alter a legally valid advance directive. The document represents the client’s own decisions, and only the client can modify or revoke it while competent to do so.

A. A client who reports frequent and painful urination B. A client who reports left arm pain following a fall C. A client who has hypertension and reports a severe headache D. A client who has heart failure and received a diuretic 30 min ago

Correct Answer is C

Explanation

Rationale:
A. A client who reports frequent and painful urination: This client likely has a urinary tract infection, which requires assessment and treatment but is not immediately life-threatening.

B. A client who reports left arm pain following a fall: Pain from trauma requires evaluation, but unless there are signs of impaired circulation or severe injury, it is lower priority than potential neurologic emergencies.

C. A client who has hypertension and reports a severe headache: A severe headache in a client with hypertension may indicate a hypertensive crisis or impending stroke. Immediate assessment is required to prevent life-threatening complications, making this the highest priority.

D. A client who has heart failure and received a diuretic 30 min ago: Monitoring is necessary to assess diuretic effects, but this client is stable and does not require immediate intervention compared with the client at risk for hypertensive emergency.

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A community health nurse is performing a home health admissions assessment with a client. The client reports being unable to obtain their prescriptions. Which of the following actions should the nurse take first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is B

Explanation

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Correct Answer is C

Explanation

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