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.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason:
Discarding the first 10 mL of urine is a common practice for obtaining a urine sample for certain tests, but it is not specifically necessary for a urine culture. In a urine culture, the goal is to obtain a sample directly from the bladder to identify any bacteria present, so discarding the initial urine is not necessary.
Choice B reason
Donning sterile gloves prior to the procedure is the appropriate action for the nurse to take. When catheterizing a toddler for a urine culture, it is essential to maintain a sterile procedure to reduce the risk of infection and ensure the safety of the child. Using sterile gloves is a crucial step in preventing contamination during the catheterization process.
Choice C reason
The size of the catheter (12-French) mentioned in option C may not be appropriate for a toddler. The size of the catheter used for a toddler would generally be smaller, depending on the age and size of the child. The appropriate catheter size should be determined based on the child's age and condition.
Choice D reason
EMLA cream is a topical anaesthetic cream used to numb the skin before certain procedures. While it might be appropriate in some cases, it is not typically used for catheterization procedures in toddlers. Catheterization is a quick procedure, and using EMLA cream may not be necessary or practical in this situation.
Correct Answer is C
Explanation
Choice A reason
Increased food intake does not show medication is effective: Increased food intake is not a specific indication of donepezil's effectiveness. While some clients with dementia may have improved appetite due to reduced agitation or confusion, it is not directly related to the medication's therapeutic effect.
Choice B reason:
Can perform ADLs independently is inappropriate: The ability to perform activities of daily living (ADLs) independently can be a positive outcome in clients with dementia. However, it may not be solely attributed to donepezil, as ADLs can be influenced by various factors, including the client's overall condition and support received.
Choice C reason:
Improved short-term memory is correct. One of the primary goals of using donepezil is to improve memory and slow the decline in cognitive abilities associated with dementia. Therefore, if a client shows improvement in short-term memory, it suggests that the medication is having a positive effect in preserving cognitive function.
Choice D reason
Enhanced mood does not show the medicine is effective: Donepezil is primarily aimed at improving cognitive function and memory, and its effects on mood may be limited. While some clients may experience mood improvements due to reduced frustration or confusion from memory loss, it is not the primary indicator of the medication's effectiveness.
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