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?
Encourage the family to assign specific tasks to individual family members.
Assist the family to establish a daily routine.
Refer the family to a grief support group.
Determine the roles of individual family members.
The Correct Answer is D
A. Assigning tasks is important but comes after understanding family dynamics.
B. Establishing a routine is beneficial but should follow assessment.
C. Referring to a support group is valuable but not the immediate first step.
D. Determining family roles helps the nurse assess coping strategies and dynamics, which is essential before planning interventions.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Draw blood specimens for culture and sensitivity: Incorrect. Blood cultures are not routinely required for cardiac catheterization.
B. Administer nitroglycerin 0.4 mg SL 30 min before the procedure: Incorrect. Nitroglycerin is not typically administered before a cardiac catheterization unless specifically ordered.
C. Obtain a CBC with differential: A complete blood count (CBC) is necessary before a cardiac catheterization to assess for potential bleeding risks, infection, or anemia.
D. Transport the client to radiology for a CT scan: Incorrect. Cardiac catheterization is performed in a specialized cardiac catheterization lab, not in radiology.
Correct Answer is ["A","B","C","D"]
Explanation
A. Abdominal circumference: The increase in abdominal circumference by 1 cm (0.4 in) since the prior assessment is concerning and may indicate a complication such as abdominal distension, which could be a sign of necrotizing enterocolitis (NEC) or other gastrointestinal issues. NEC is a serious condition that is common in preterm infants, especially those receiving enteral feedings.
B. Gestational age: Being born at 34 weeks gestation is a significant risk factor. Prematurity increases the risk for complications like respiratory distress syndrome (RDS), infections, and feeding difficulties. Preterm infants are also at risk for problems with thermoregulation, which is why the neonate is on a radiant warmer.
C. Respiratory distress: The presence of substernal retractions, nasal flaring, and an elevated respiratory rate (70/min) indicates respiratory distress. Preterm neonates, especially those born at 34 weeks, are at risk for RDS due to insufficient surfactant production, which can lead to difficulty breathing and hypoxemia.
D. UAC: The umbilical arterial catheter (UAC) is commonly used for monitoring blood pressure and obtaining blood samples in neonates. However, it carries a risk for complications such as infection, thrombosis, and injury to blood vessels. This is an invasive device that could contribute to complications.
E. Feeding method (Continuous breast milk feedings via OG tube): Although feeding via an orogastric tube is a standard method for preterm neonates, it does not pose an immediate risk factor in this case. The method of feeding itself is not a complication risk. However, complications like feeding intolerance or aspiration can arise, which would require further monitoring.
G. 5-minute Apgar score: A 5-minute Apgar score of 7 is considered an acceptable score for a neonate. Although it indicates some initial difficulty, this score does not present a significant risk factor for complications by itself. A lower score would be more concerning, but a score of 7 typically suggests the neonate is transitioning well.
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