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 C
Explanation
Choice A reason: Having the client's daughter communicate information about the procedure is not an action that the nurse should take. The daughter may not be a reliable or accurate interpreter, as she may have limited language skills, lack medical knowledge, or be influenced by her emotions or biases. The nurse should use a qualified interpreter who can ensure the confidentiality, accuracy, and completeness of the communication.
Choice B reason: Arranging for a member of the client's community to interpret the teaching is not an action that the nurse should take. The member of the client's community may not be a qualified or impartial interpreter, as he or she may have a personal or professional relationship with the client, or may have a conflict of interest or a hidden agenda. The nurse should use a professional interpreter who can maintain the boundaries, objectivity, and neutrality of the communication.
Choice C reason: Identifying the client's spoken dialect prior to contacting an interpreter is an action that the nurse should take. This will help the nurse to find an appropriate interpreter who can communicate effectively and respectfully with the client. The nurse should also consider the client's cultural background, preferences, and needs when selecting an interpreter.
Choice D reason: Using professional terminology when providing education prior to the procedure is not an action that the nurse should take. The nurse should use simple and clear language that the client can understand, and avoid using jargon, slang, or idioms that may confuse or offend the client. The nurse should also check the client's comprehension and ask for feedback throughout the communication.
Correct Answer is D
Explanation
Choice A reason: Bradycardia is not a manifestation of alcohol withdrawal, but rather a sign of low heart rate. Alcohol withdrawal typically causes tachycardia, or high heart rate, as the body tries to compensate for the sudden absence of alcohol.
Choice B reason: Hypothermia is not a manifestation of alcohol withdrawal, but rather a sign of low body temperature. Alcohol withdrawal typically causes hyperthermia, or high body temperature, as the body reacts to the withdrawal symptoms.
Choice C reason: Increased appetite is not a manifestation of alcohol withdrawal, but rather a sign of hunger or craving. Alcohol withdrawal typically causes decreased appetite, or anorexia, as the body loses interest in food and suffers from nausea and vomiting.
Choice D reason: Insomnia is a manifestation of alcohol withdrawal, and one of the most common and distressing symptoms. Alcohol withdrawal causes insomnia, or difficulty falling or staying asleep, as the body experiences anxiety, agitation, and nightmares.
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