A home health nurse is conducting an initial home visit for a client who has terminal breast cancer. The client has two school-age children and a limited support system. Which of the following is the priority nursing action?
Inform the client of available community resources.
Assist the client in finding child care options.
Agree upon short-term goals for the client.
Ask the client about their understanding of the diagnosis.
The Correct Answer is D
A. Inform the client of available community resources is an important action because the client will likely need additional support, such as hospice care, counseling, or child care services. However, before providing resources, the nurse must assess the client’s understanding of their diagnosis to ensure any interventions are tailored to their current needs and readiness.
B. Assist the client in finding child care options - While important, addressing community resources takes precedence as it may encompass finding child care options as well.
C. Agree upon short-term goals for the client - Establishing goals is important but may come after addressing immediate needs.
D. Ask the client about their understanding of the diagnosis is the priority action. Before any other interventions, the nurse must assess the client’s knowledge and perception of their condition. This foundational step allows the nurse to provide appropriate education, clarify any misconceptions, and ensure that all care planning aligns with the client’s needs, values, and readiness to engage in discussions about their care.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A.
A. A BMI of 20 falls within the healthy weight range for adults, indicating that the client's weight is appropriate for his height.
B. A BMI of 20 is not indicative of malnutrition. Malnutrition is typically associated with lower BMIs.
C. A BMI of 20 is not within the overweight range, as overweight is typically defined as a BMI between 25 and 29.9.
D. A BMI of 20 is not within the obesity range, as obesity is typically defined as a BMI of 30 or higher.
Correct Answer is D
Explanation
- Choice A: The recommended hepatitis vaccine series is not a series of four. The Advisory Committee on Immunization Practices (ACIP) recommends a three-dose series for hepatitis B vaccination.
- Choice B: Hepatitis B is not typically transmitted by contaminated food. It is primarily spread through direct contact with infectious blood, semen, or other body fluids.
- Choice C: While there is some evidence suggesting a link between chronic hepatitis C infection and an increased risk of renal cell carcinoma, the statement is not universally accepted as fact and more research is needed to establish a definitive connection.
- Choice D: Individuals with a history of hepatitis B or C are generally ineligible to donate blood due to the risk of transmission of these bloodborne viruses.
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