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 C
Explanation
Choice A reason: Higherthannormal number of CD4+ Tcells and CD8+ Tcells are normal is not a laboratory value that most adults with human immunodeficiency virus will exhibit, because it does not reflect the effect of the virus on the immune system. CD4+ Tcells and CD8+ Tcells are types of white blood cells that play a key role in the immune response. CD4+ Tcells are helper cells that activate and coordinate other immune cells, while CD8+ Tcells are cytotoxic cells that kill infected or abnormal cells. Human immunodeficiency virus infects and destroys CD4+ Tcells, which impairs the immune function and increases the risk of opportunistic infections and cancers. CD8+ Tcells are not directly affected by the virus, but they may increase in number as a compensatory mechanism to fight the infection. Therefore, most adults with human immunodeficiency virus will have lowerthannormal number of CD4+ Tcells and higher than normal CD8+ Tcells.
Choice B reason: Lowerthannormal number of CD4+ Tcells and CD8+ Tcells are normal is not a laboratory value that most adults with human immunodeficiency virus will exhibit, because it does not reflect the effect of the virus on the immune system, as explained above. Lowerthannormal number of CD4+ Tcells and CD8+ Tcells are normal may indicate a condition that affects both types of Tcells, such as aplastic anemia, chemotherapy, radiation therapy, or immunosuppressive drugs.
Choice C reason: Lowerthannormal number of CD4+ Tcells and higher than normal CD8+ Tcells is a laboratory value that most adults with human immunodeficiency virus will exhibit, because it reflects the effect of the virus on the immune system, as explained above. Lowerthannormal number of CD4+ Tcells and higher than normal CD8+ Tcells may indicate the progression of the infection and the severity of the immunodeficiency. The normal range of CD4+ Tcells is 500 to 1500 cells per microliter of blood, while the normal range of CD8+ Tcells is 150 to 1000 cells per microliter of blood.
Choice D reason: Higherthannormal number of CD4+ Tcells and CD8+ Tcells are low is not a laboratory value that most adults with human immunodeficiency virus will exhibit, because it does not reflect the effect of the virus on the immune system, as explained above. Higherthannormal number of CD4+ Tcells and CD8+ Tcells are low may indicate a condition that affects CD8+ Tcells, such as leukemia, lymphoma, or corticosteroid therapy.
Correct Answer is C
Explanation
Choice A reason: Pulmonary embolism is not the correct answer, because it is a condition that affects the lungs, not the arm. Pulmonary embolism is a blockage of one or more arteries in the lungs by a blood clot, which can cause shortness of breath, chest pain, and coughing up blood.
Choice B reason: Ischial tuberosity is not the correct answer, because it is a bony projection on the pelvis, not the arm. Ischial tuberosity is the part of the pelvis that supports the weight of the body when sitting, and it can be injured by trauma, overuse, or infection.
Choice C reason: Compartment syndrome is the correct answer, because it is a condition that affects the arm, and it matches the symptoms of the client. Compartment syndrome is a serious complication of a traumatic injury, such as a fracture, that causes increased pressure within a closed space of the body, such as the forearm. This pressure can compromise the blood flow and nerve function of the affected area, causing pain, numbness, weakness, and pale skin.
Choice D reason: Broken arm syndrome is not the correct answer, because it is not a real medical condition. Broken arm syndrome is a madeup term that does not describe any specific diagnosis or treatment.
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