A home health nurse is reviewing messages from a group of clients. Which of the following clients should the nurse contact first?
A mother who reports that her son vomited after a dose of methylphenidate
A client who has COPD and reports an oxygen saturation of 90%
A client who reports that her new colostomy stoma appears purple
A client who reports feeling a vibration in his new internal arteriovenous graft for dialysis
The Correct Answer is C
The mother reporting vomiting in choice A may be concerning, but it is a known side effect of methylphenidate, and the client should be monitored for any further symptoms. A client who has COPD and reports an oxygen saturation of 90%. An oxygen saturation of 90% in COPD is within normal due to the chronic hypoxia.The purple appearance of a colostomy stoma in choice C may indicate ischemia or necrosis, and is an urgent concern.The feeling of a vibration in a new arteriovenous graft for dialysis in choice D may indicate an arterial steal syndrome, but it is not a medical emergency, and the client can be instructed to follow up with the provider. Therefore, the correct answer is choice B.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
The correct answer is Choice A because, "Describe the place where you are currently living." Asking the client to describe their living situation will provide the case manager with information about the client's home environment and help identify any potential barriers to safe care. This information can then be used to develop a safe and effective discharge plan, which may include arranging for a special bed at home.
Choice B is wrong because, "Apply moisture barrier ointment three times a day," is not the correct answer because it focuses on a specific aspect of the client's care, rather than considering the broader context of their living situation. Choice C is wrong because, "Eat a balanced diet with high-protein snacks," is not the correct answer as it also focuses on the client's care, rather than their living situation. Choice D is wrong because, "A social worker can help you with the cost of supplies," is not the correct answer as it may not be the most pressing concern at the time of discharge planning.
Correct Answer is C
Explanation
The correct answer is Choice C because, "Refer clients to the appropriate community agency if signs of abuse are evident." This is the correct answer because it is an appropriate secondary prevention strategy related to violence and abuse. By referring clients to the appropriate community agency, the nurse is providing a proactive measure to prevent further harm and ensure that the client receives appropriate care.
Choice Ais wrong because, "Teach a parenting skills class at a child development center," is not the correct answer because it is a primary prevention strategy and not related to violence and abuse.
Choice Bis wrong because, "Assess clients for withdrawal and passivity during home health visits," is not the correct answer because it is a secondary prevention strategy related to depression, not violence and abuse.
Choice Dis wrong because, "Coordinate a personal defense program at a local agency," is not the correct answer because it is a tertiary prevention strategy and not related to violence and abuse.
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