A homeless client arrives in the emergency room. The client verbalizes an inability to bathe for at least one month. What is the nurse's priority?
Inspect the client's skin
Provide a towel and show the client to the shower
Ask if the client has been to a homeless shelter recently
Call a social worker
The Correct Answer is A
Choice A reason: Inspecting the client's skin is the nurse's priority, because it is the most urgent and relevant action. Inspecting the client's skin can help identify any signs of infection, injury, or infestation, such as wounds, rashes, ulcers, or lice. The client's skin may be compromised by the lack of hygiene, exposure to the elements, or poor nutrition. The client's skin may also be a source of transmission of pathogens to other clients or staff. Therefore, inspecting the client's skin is essential for the assessment, diagnosis, and treatment of the client's condition.
Choice B reason: Providing a towel and showing the client to the shower is not the nurse's priority, because it is not the most urgent and relevant action. Providing a towel and showing the client to the shower is an important intervention, but it should be done after inspecting the client's skin and ensuring the safety and infection prevention of the client and others. The client may have wounds, rashes, or ulcers that need to be cleaned, dressed, or treated before bathing. The client may also have lice or scabies that need to be isolated and treated with special shampoos or creams before bathing. The client may also need assistance or supervision during bathing, depending on the client's physical and mental status.
Choice C reason: Asking if the client has been to a homeless shelter recently is not the nurse's priority, because it is not the most urgent and relevant action. Asking if the client has been to a homeless shelter recently is an important question, but it should be done after inspecting the client's skin and providing a towel and showing the client to the shower. The client's history of homelessness and shelter use may provide some information about the client's social and environmental factors, such as exposure to violence, abuse, or disease, or access to resources, services, or support. However, this information is not as critical as the client's skin condition, which may require immediate attention and care.
Choice D reason: Calling a social worker is not the nurse's priority, because it is not the most urgent and relevant action. Calling a social worker is an important referral, but it should be done after inspecting the client's skin, providing a towel and showing the client to the shower, and asking if the client has been to a homeless shelter recently. The social worker can help the client with the psychosocial and practical aspects of homelessness, such as finding a shelter, applying for benefits, accessing health care, or addressing mental health or substance abuse issues. However, this referral is not as urgent as the client's skin condition, which may require immediate attention and care.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["B","C","E"]
Explanation
Choice A reason: "I will monitor my nutrition and fluid status." is not a statement that requires further teaching or clarification, because it is correct and appropriate. Monitoring nutrition and fluid status is an important selfcare measure for people with HIV, as it can help maintain the immune function, prevent dehydration, and promote healing. People with HIV should eat a balanced and varied diet, drink enough water, and avoid foods or drinks that can cause diarrhea, nausea, or vomiting.
Choice B reason: "Because I have HIV, that means I'm an AIDS patient." is a statement that requires further teaching or clarification, because it is incorrect and misleading. Having HIV does not mean that one has AIDS, but rather that one is at risk of developing AIDS. HIV is the virus that causes AIDS, which is the most advanced stage of the infection. AIDS is diagnosed when the CD4+ Tcell count drops below 200 cells per microliter of blood, or when the person develops one or more opportunistic infections or cancers. People with HIV can delay or prevent the progression to AIDS by taking antiretroviral drugs, which can suppress the viral load and improve the immune function.
Choice C reason: "I can still have unprotected intercourse with my partner since he doesn't have HIV." is a statement that requires further teaching or clarification, because it is incorrect and misleading. Having unprotected intercourse with a partner who does not have HIV is not safe or advisable, as it can expose the partner to the risk of contracting HIV. HIV is transmitted through sexual contact, as well as through blood, semen, vaginal fluid, or breast milk. People with HIV should use condoms or other barrier methods during intercourse, regardless of the HIV status of their partner. People with HIV should also inform their partner about their infection, and encourage them to get tested and treated if needed.
Choice D reason: "I need to ensure that I place my needles in a proper needle disposal container." is not a statement that requires further teaching or clarification, because it is correct and appropriate. Placing needles in a proper needle disposal container is an important infection prevention measure for people with HIV, as it can prevent the accidental or intentional reuse or sharing of needles, which can transmit HIV or other bloodborne diseases. People with HIV should use new and sterile needles for injections, and dispose of them in a punctureresistant and leakproof container, which can be obtained from a pharmacy, clinic, or health department.
Choice E reason: "I can spread this through contact with surfaces, so I need to wear gloves in public." is a statement that requires further teaching or clarification, because it is incorrect and exaggerated. Spreading HIV through contact with surfaces is not possible or likely, as the virus does not survive long outside the body, and is not transmitted by casual contact, such as touching, hugging, or sharing utensils. Wearing gloves in public is not necessary or advisable, as it can create a false sense of security, stigma, or discrimination. People with HIV should practice good hygiene, such as washing hands, covering coughs, and cleaning wounds, but they do not need to wear gloves or other protective equipment in public.
Correct Answer is ["A","B","E"]
Explanation
Choice A reason: Padding hard surfaces is a nursing intervention that decreases the risk of pressure injuries, because it reduces the pressure, shear, and friction on the skin and underlying tissues. Hard surfaces, such as bed rails, wheelchair arms, or footrests, can cause compression or irritation of the skin, especially over the bony prominences. Padding hard surfaces with foam, gel, or air cushions can provide protection and comfort for the client.
Choice B reason: Keeping head of bed (HOB) at or less than 30 degrees is a nursing intervention that decreases the risk of pressure injuries, because it prevents the sliding or shifting of the client in bed. Sliding or shifting can cause shear and friction on the skin, especially over the sacrum, coccyx, or heels. Keeping head of bed (HOB) at or less than 30 degrees can maintain the alignment and stability of the client in bed.
Choice C reason: Keeping head of bed (HOB) elevated to 75 degrees is not a nursing intervention that decreases the risk of pressure injuries, but rather one that increases the risk of pressure injuries. Elevating the head of bed (HOB) to 75 degrees can cause the client to slide or shift in bed, which can increase the shear and friction on the skin, as explained above. Elevating the head of bed (HOB) to 75 degrees can also increase the pressure on the sacrum, coccyx, or heels, which can impair the blood flow and oxygen delivery to the skin and tissues.
Choice D reason: Having client sit in wheelchair as much as possible is not a nursing intervention that decreases the risk of pressure injuries, but rather one that increases the risk of pressure injuries. Sitting in wheelchair as much as possible can cause prolonged pressure, shear, and friction on the skin and underlying tissues, especially over the ischial tuberosities, sacrum, coccyx, or heels. Sitting in wheelchair as much as possible can also reduce the mobility and activity of the client, which can affect the blood circulation and muscle tone.
Choice E reason: Placing pillows between bony surfaces is a nursing intervention that decreases the risk of pressure injuries, because it relieves the pressure, shear, and friction on the skin and underlying tissues. Bony surfaces, such as the ankles, knees, hips, or elbows, can cause compression or irritation of the skin, especially when they are in contact with each other or with the bed. Placing pillows between bony surfaces can provide cushioning and separation for the skin and tissues.
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