A home health nurse is scheduled for a first time visit to a client. Which of the following should the nurse perform first?
Blood pressure screening
Mental status examination
Review of the neighborhood
Family history
The Correct Answer is C
Choice A reason: Blood pressure screening is not the first thing that the nurse should perform, as it is a physical assessment that can be done later in the visit. Blood pressure screening is important to monitor the client's cardiovascular health and risk of hypertension, but it is not a priority for the initial visit.
Choice B reason: Mental status examination is not the first thing that the nurse should perform, as it is a psychological assessment that can be done later in the visit. Mental status examination is important to evaluate the client's cognitive, emotional, and behavioral functioning and identify any mental health issues, but it is not a priority for the initial visit.
Choice C reason: Review of the neighborhood is the first thing that the nurse should perform, as it is an environmental assessment that can provide valuable information about the client's living conditions, safety, and resources. Review of the neighborhood is important to identify any potential hazards, barriers, or needs that may affect the client's health and well-being, and to plan appropriate interventions and referrals.
Choice D reason: Family history is not the first thing that the nurse should perform, as it is a genetic and social assessment that can be done later in the visit. Family history is important to determine the client's risk of inheriting or developing certain diseases, and to understand the client's family dynamics and support system, but it is not a priority for the initial visit.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A reason: You will not be taking a once weekly dose of disulfiram to help control withdrawal symptoms during treatment. Disulfiram is a medication that causes unpleasant reactions, such as nausea, vomiting, and headache, when alcohol is consumed. It is used to deter relapse, not to treat withdrawal symptoms. It is also taken daily, not weekly.
Choice B reason: Remaining physically active will not help to minimize drowsiness and chills associated with initial alcohol withdrawal. Physical activity may worsen dehydration, electrolyte imbalance, and blood pressure changes that occur during alcohol withdrawal. It may also increase the risk of seizures and delirium tremens. The nurse should monitor the client's vital signs, fluid and electrolyte status, and mental status, and administer medications as prescribed to manage withdrawal symptoms.
Choice C reason: Attending Al-Anon meetings will not help you identify a role model to assist you with making needed changes. Al-Anon is a support group for family members and friends of people with alcohol use disorder. It helps them cope with the effects of living with or caring for someone with alcohol problems. It does not provide role models or guidance for people with alcohol use disorder. The nurse should encourage the client to attend Alcoholics Anonymous (AA) meetings, which are peer support groups for people who want to stop drinking.
Choice D reason: You will begin learning functional skills to replace defense mechanisms and behaviors while in treatment. This is an appropriate statement for the nurse to include in the discussion, as it reflects one of the goals of treatment for alcohol use disorder. The nurse should help the client identify and modify the cognitive, emotional, and behavioral factors that contribute to alcohol use. The nurse should also teach the client coping skills, stress management techniques, and relapse prevention strategies.
Correct Answer is C
Explanation
Choice A reason: Helping the client apply for Medicare is not the best action by the nurse, as Medicare is a federal health insurance program for people who are 65 or older, disabled, or have end-stage renal disease. The client does not meet any of these criteria and may not be eligible for Medicare.
Choice B reason: Exploring options for alternative therapies is not the best action by the nurse, as alternative therapies may not be effective or safe for treating tuberculosis. Tuberculosis is a serious bacterial infection that requires specific antibiotics to cure. Alternative therapies may also interfere with the prescribed medication or cause adverse effects.
Choice C reason: Arranging for medication through local agencies is the best action by the nurse, as it ensures that the client receives the appropriate treatment for tuberculosis. Local agencies may have programs or resources that can help the client access free or low-cost medication. The nurse should also educate the client about the importance of adhering to the medication regimen and completing the course of treatment.
Choice D reason: Sending the client to the nearest facility for further evaluation is not the best action by the nurse, as it may delay the initiation of treatment and increase the risk of transmission of tuberculosis to others. The client already has a diagnosis of tuberculosis and needs to start the treatment as soon as possible. The nurse should also advise the client to wear a mask and avoid close contact with others until the infection is no longer contagious.
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