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.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A reason: A client who has superficial partial-thickness burn injuries over 5% of his body is not the highest priority for treatment. This type of burn injury affects only the epidermis and the upper layer of the dermis, and causes pain, redness, and blisters. The client may need fluid replacement, pain management, and wound care, but is not in immediate danger of life-threatening complications.
Choice B reason: A client who has a femur fracture with a 2+ pedal pulse is not the highest priority for treatment. This type of fracture involves the breakage of the thigh bone, which is the largest and strongest bone in the body. The client may experience severe pain, swelling, deformity, and bleeding. A 2+ pedal pulse indicates that the blood flow to the lower extremity is adequate, but not optimal. The client may need immobilization, traction, surgery, and infection prevention, but is not in immediate danger of life-threatening complications.
Choice C reason: A client who is ambulatory and exhibits manic behavior is not the highest priority for treatment. This type of behavior involves a state of elevated mood, energy, and activity, which may be caused by stress, trauma, or a mental disorder. The client may experience euphoria, irritability, impulsivity, and poor judgment. The client may need psychological support, medication, and safety measures, but is not in immediate danger of life-threatening complications.
Choice D reason: A client who has a rigid abdomen with manifestations of shock is the highest priority for treatment. This type of condition involves a severe injury to the abdominal organs, such as the liver, spleen, or intestines, which may cause internal bleeding, inflammation, and infection. The client may experience pain, tenderness, distension, and guarding of the abdomen, as well as signs of shock, such as hypotension, tachycardia, pallor, and confusion. The client may need fluid resuscitation, blood transfusion, surgery, and antibiotics, and is in immediate danger of life-threatening complications.
Correct Answer is B
Explanation
Choice A reason: People who have substance use disorders are not the fastest growing segment of the homeless population, although they are a significant and vulnerable group. Substance use disorders may contribute to or result from homelessness, but they are not the primary cause of the increase in homelessness.
Choice B reason: Families who have children are the fastest growing segment of the homeless population, according to the U.S. Department of Housing and Urban Development (HUD). The number of homeless families with children increased by 9% from 2019 to 2020, and they accounted for 34% of the total homeless population in 2020. The main causes of family homelessness are lack of affordable housing, poverty, unemployment, domestic violence, and health problems.
Choice C reason: Adolescent runaways are not the fastest growing segment of the homeless population, although they are a high-risk and underserved group. Adolescent runaways may face challenges such as abuse, exploitation, mental health issues, and lack of education and employment opportunities. However, the number of homeless youth is difficult to estimate due to their hidden and transient nature.
Choice D reason: Men who are unemployed are not the fastest growing segment of the homeless population, although they are a large and diverse group. Men who are unemployed may face barriers such as low wages, lack of skills, discrimination, and health problems. However, the number of homeless men has decreased by 5% from 2019 to 2020, and they accounted for 60% of the total homeless population in 2020.
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