A home health nurse is planning the initial home visit for a client who has dementia and lives with his adult son's family. Which of the following actions should the nurse take first during the visit?
Encourage the family to join a support group.
Engage the family in informal conversation.
Provide the family with information about respite care.
Educate the family regarding the progression of dementia.
The Correct Answer is B
. Engage the family in informal conversation. The first step in caring for a client with dementia is to establish a relationship of trust and comfort with the client and their family. Engaging the family in informal conversation can help the nurse gain insight into the family's needs and concerns, as well as provide an opportunity to establish rapport. Encouraging the family to join a support group, providing information about respite care, and educating the family regarding the progression of dementia are important steps in caring for a client with dementia, but they should follow the initial step of engaging the family in informal conversation.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Hemianopsia is a visual field defect in which there is a loss of vision in one-half of the visual field. It can be caused by a number of conditions, including stroke, brain tumors, and traumatic brain injury. It is a significant finding that requires immediate reporting to the provider, as it can indicate a serious underlying condition that requires further evaluation and treatment. Hemianopsia can significantly impact a client's ability to perform activities of daily living, mobility, and safety. Conjunctivitis is inflammation of the conjunctiva, which can cause redness, itching, and discharge. While it is important
to assess and treat conjunctivitis, it is not a priority finding that requires immediate reporting to the provider. Increased sensitivity to glare is a common age-related change in vision, and while it can be bothersome, it is not typically a priority finding that requires immediate reporting to the provider. Decreased near vision is another common age-related change in vision, and while it can be an important finding to address with the client, it is not typically a priority finding that requires immediate reporting to the provider.
Correct Answer is B
Explanation
In a mass casualty incident (MCI) like a train crash, triage is based on the severity of injuries and likelihood of survival using the START (Simple Triage and Rapid Treatment) system. Clients are categorized as Immediate (Red), Delayed (Yellow), Minor (Green), or Expectant (Black).
A. A client with a humerus fracture and a 2+ radial pulse (Yellow - Delayed): The client is stable and not the highest priority for immediate transport.
B. A client with full-thickness burns over 30% TBSA (Red - Immediate): This client has life-threatening injuries requiring urgent treatment for airway support, fluid resuscitation, and burn care.
C. A client with agonal respirations and fixed, dilated pupils (Black - Expectant): This client is unlikely to survive even with treatment, so in an MCI, resources should be allocated to those with a higher chance of survival.
D. An ambulatory client with a nosebleed and dizziness (Green - Minor): This client is walking wounded and can wait for medical care.
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