A nurse is caring for a client whose partner died in a fire that destroyed their home. Which of the following actions should the nurse take first?
Empower the client to feel that he is in charge of his life.
Find the client a temporary shelter where he can feel safe.
Determine if the client has thoughts about self-harm.
Review the client's available social support system
The Correct Answer is C
Choice A reason
Empowering the client to feel in charge of his life is essential for promoting coping and a sense of control over the situation. However, it may not be the first priority when the client's safety is in question.
Choice B reason:
Finding the client, a temporary shelter where he can feel safe is important for meeting the client's immediate physical needs, but it can be addressed after ensuring his emotional well-being and safety.
Choice C reason
The client's partner has died in a traumatic event, and the loss of both a loved one and their home can be emotionally overwhelming and distressing. The nurse's first priority should be to assess the client's safety and well-being, especially considering the potential for thoughts of self-harm or suicide.
Assessing for thoughts of self-harm is critical because the client may be experiencing intense grief, guilt, or hopelessness, which can increase the risk of self-harm or suicidal ideation. Identifying these thoughts early allows the nurse to initiate appropriate interventions, provide emotional support, and involve mental health professionals if necessary.
Choice D reason
Reviewing the client's available social support system is significant for addressing the client's emotional needs and establishing a support network. However, ensuring the client's safety takes precedence over this action.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A reason:
"I will avoid using my microwave oven at home because of the ICD."This statement is incorrect. Using a microwave oven does not interfere with the functioning of an ICD. It is safe for clients with ICDs to use microwave ovens.
Choice B reason:
"I can hold my cell phone on the same side of my body as the ICD."This statement is incorrect Holding a cell phone on the same side of the body as the ICD should not cause any harm or interfere with the device's functioning.
Choice C reason:
"I will wear loose clothing over my ICD." This statement is correct and demonstrates understanding of the teaching. Wearing loose clothing over the ICD helps prevent excessive pressure or friction on the device and reduces the risk of dislodging the ICD leads or causing discomfort.
Choice D reason:
"I will soak in the tub rather than showering." This statement is incorrect. Avoiding showers is not necessary for clients with ICDs. Taking showers is generally safe for individuals with ICDs, as the device is designed to be waterproof and withstand such conditions.
Correct Answer is D
Explanation
Choice A reason:
"I should gargle with an alcohol-based mouthwash to kill germs”. This statement is not appropriate. Using an alcohol-based mouthwash is not recommended for a client with stomatitis. Alcohol can be irritating to the already inflamed mucous membranes and may worsen the condition. Instead, the client should use a mild, non-alcohol-based mouthwash or rinse as prescribed by the healthcare provider.
Choice B option
"I should limit my intake of dairy products to prevent nausea." This statement is not appropriate. While some clients may experience nausea during radiation therapy, limiting dairy products is not specifically related to stomatitis management. The client should follow any dietary recommendations provided by the healthcare provider or a registered dietitian to address nausea or other dietary concerns.
Choice C option
"I should moisten my lips with lemon-glycerine swabs." This is incorrect because lemon-glycerine swabs can be drying and irritating to the oral mucosa, which may exacerbate stomatitis symptoms. Instead, using a gentle, non-irritating lip balm or petroleum jelly is preferred.
Choice D option
"I should use a soft-bristle toothbrush to clean my teeth after meals." This response indicates an understanding of the teaching because a soft-bristle toothbrush is gentle on the gums and oral tissues, which is important for a client with stomatitis, as it helps to minimize irritation and injury.
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