A community health nurse receives a referral for a family home visit. Which of the following tasks should the nurse perform first?

Clarify the source of the referral

Contact the family by phone

Implement the nursing process.

Schedule a time for the home visit

Answer and Explanation

The Correct Answer is A

Rationale:

A. Clarify the source of the referral: Before taking any action, the nurse must first clarify the referral source to understand why the visit is needed, the client’s health status, and any specific concerns or priorities. This ensures the nurse has accurate and complete information to plan the visit safely and effectively.

B. Contact the family by phone: While contacting the family is necessary to arrange the visit, it should occur only after the nurse understands the purpose of the referral and any special considerations to communicate relevant information.

C. Implement the nursing process: Implementing the nursing process requires assessment and planning. The nurse cannot proceed to intervention without first obtaining information about the referral and preparing appropriately.

D. Schedule a time for the home visit: Scheduling is important for logistics, but it should occur after clarifying the referral and understanding the family’s needs to ensure the visit is purposeful and safe.

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Correct Answer is D

Explanation

Rationale:

A. Lack of empathy: This is characteristic of narcissistic personality disorder rather than obsessive-compulsive personality disorder (OCPD). Clients with OCPD may appear rigid and controlling but do not typically demonstrate a profound lack of empathy.

B. Fear of abandonment: This is a hallmark feature of borderline personality disorder, not OCPD. Clients with OCPD usually struggle with control, orderliness, and perfectionism rather than intense fears of being abandoned.

C. Distrust of others: Distrust is more indicative of paranoid personality disorder. While OCPD clients may be critical or controlling, pervasive suspicion and mistrust are not primary features.

D. Focus on perfectionism: A hallmark manifestation of OCPD is a preoccupation with order, rules, and perfectionism. Clients may become inflexible, excessively devoted to work, and unable to delegate tasks due to their high standards, making this the expected finding.

A. Pull the client's pinna down and back to apply the solution. B. Perform the procedure using sterile gloves. C. Administer the irrigation solution at room temperature to the ear D. Apply a stream of pressure as long as the client can tolerate.

Correct Answer is C

Explanation

Rationale:

A. Pull the client's pinna down and back to apply the solution.: Pulling the pinna down and back is the correct technique for infants and young children due to the angle of the ear canal. For adults, the pinna should be pulled up and back to straighten the ear canal. Using the incorrect direction can prevent proper visualization and reduce effectiveness of the irrigation.

B. Perform the procedure using sterile gloves.: Ear irrigation is a clean procedure, not a sterile one. The external ear canal is not a sterile environment, and using sterile gloves does not reduce infection risk. Clean gloves provide adequate protection while maintaining proper hygiene during cerumen removal.

C. Administer the irrigation solution at room temperature to the ear.: Using a solution at room temperature prevents stimulation of the vestibular system, which can cause dizziness, nausea, and vertigo. A temperature-neutral solution promotes client comfort and reduces physiologic irritation while effectively helping soften and remove cerumen.

D. Apply a stream of pressure as long as the client can tolerate.: Using forceful or prolonged pressure can damage the tympanic membrane or push cerumen deeper into the canal. Irrigation should be done gently, allowing the solution to flow along the canal wall and stopping immediately if the client reports pain or dizziness to avoid injury.

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System	Findings
General	Adult child accompanying parent reports decline in client, expressing concern over memory and thought process, appetite, and self-care. Adult child states, "My sibling and I hired help at home for my parent. We thought that would help but it has not. I found the title to the car today, signed over to me."
Physical	Client makes poor eye contact, speaks in a monotone voice, and has a lack of facial expression. Client reports sleeping 7 hr a night and getting up "once or twice per night to go to the bathroom." Client reports not wanting to eat anymore. Client's child reports their parent has lost about 8 lb in the past month. Heart rate 68/min
Affect	Client says, "Why don't you just leave me? I am of no use."

A community health nurse receives a referral for a family home visit. Which of the following tasks should the nurse perform first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assessing a client who has obsessive-compulsive personality disorder. Which of the following manifestations should the nurse expect?

Correct Answer is D

Explanation

A nurse is preparing to irrigate an adult client's ear due to cerumen accumulation. Which of the following actions should the nurse take?

Correct Answer is C

Explanation

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