A nurse is caring for a client who is homeless. Which of the following actions should the nurse take first?
Determine the client's understanding of her living situation.
Assist the client to develop goals for obtaining shelter.
Discuss the risks of being homeless with the client.
Develop client teaching using a variety of strategies.
The Correct Answer is A
Choice A reason: Determining the client's understanding of her living situation is the first action that the nurse should take. This is based on the principle of client-centered care, which states that the nurse should respect the client's values, preferences, and needs, and involve the client in the decision-making process. The nurse should assess the client's perception of her homelessness, the factors that contributed to it, and the resources that are available to her.
Choice B reason: Assisting the client to develop goals for obtaining shelter is not the first action that the nurse should take. This is an important intervention, but it should be done after the nurse has assessed the client's understanding of her living situation and explored the client's readiness and motivation to change.
Choice C reason: Discussing the risks of being homeless with the client is not the first action that the nurse should take. This is an important intervention, but it should be done after the nurse has assessed the client's understanding of her living situation and established a trusting relationship with the client. The nurse should avoid being judgmental or paternalistic, and instead use a harm reduction approach that focuses on minimizing the negative consequences of homelessness.
Choice D reason: Developing client teaching using a variety of strategies is not the first action that the nurse should take. This is an important intervention, but it should be done after the nurse has assessed the client's understanding of her living situation and identified the client's learning needs and preferences. The nurse should use strategies that are appropriate for the client's literacy level, language, culture, and cognitive ability.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A reason: Reviewing flashcards that identify holding techniques with the group is not an instructional strategy that the nurse should use to promote psychomotor learning. This is a cognitive strategy that can help the participants to recall and recognize the information, but it does not involve the practice or performance of the skills.
Choice B reason: Showing the group a video on breastfeeding techniques is not an instructional strategy that the nurse should use to promote psychomotor learning. This is an affective strategy that can help the participants to observe and appreciate the techniques, but it does not involve the practice or performance of the skills.
Choice C reason: Facilitating a discussion group about the benefits of breastfeeding is not an instructional strategy that the nurse should use to promote psychomotor learning. This is an affective strategy that can help the participants to express and share their opinions and feelings, but it does not involve the practice or performance of the skills.
Choice D reason: Providing dolls for the participants to demonstrate positioning is an instructional strategy that the nurse should use to promote psychomotor learning. This is a psychomotor strategy that can help the participants to apply and practice the skills in a simulated setting, and to receive feedback and guidance from the nurse.
Correct Answer is C
Explanation
Choice A reason: The client dressing her affected side first is not a finding that the nurse should report to the interprofessional care team, as it indicates that the client is following the proper technique for dressing after a stroke. Dressing the affected side first helps the client maintain range of motion and prevent contractures of the affected limbs.
Choice B reason: The client bearing weight on their arms when using crutches is not a finding that the nurse should report to the interprofessional care team, as it is a normal and expected way of using crutches. Bearing weight on the arms helps the client balance and support their body weight while walking with crutches.
Choice C reason: The client coughing when swallowing her medications is a finding that the nurse should report to the interprofessional care team, as it indicates that the client may have dysphagia, or difficulty swallowing, which is a common complication of stroke. Dysphagia can increase the risk of aspiration, pneumonia, dehydration, and malnutrition. The nurse should assess the client's swallowing ability and refer them to a speech-language pathologist for further evaluation and intervention.
Choice D reason: The client's caregiver filling a pill organizer weekly is not a finding that the nurse should report to the interprofessional care team, as it is a positive and helpful way of managing the client's medications. Filling a pill organizer weekly can help the client and the caregiver remember the medication names, doses, and schedules, and prevent medication errors or omissions.
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