A nurse is caring for several clients at a homeless shelter who report manifestations of infectious diarrhea. Which of the following actions should the nurse take first?
Obtain an individual client exposure history.
Provide teaching about hand washing for the clients.
Refer the clients for financial assistance to receive medications.
Arrange for the clients to see a health care provider.
The Correct Answer is A
Rationale:
A. The first action is to assess and gather information about potential sources of infection, onset of symptoms, and possible exposure routes. This assessment is critical for identifying the cause, scope, and risk of transmission of infectious diarrhea and guides subsequent interventions. It follows the nursing process priority of assessment before planning or intervention.
B. While client education is important to prevent spread, it should occur after the nurse has assessed the exposure and determined the cause. Immediate education without understanding the exposure may not address the key risks.
C. Referral for financial support is important for access to treatment, but it is a secondary action. The priority is assessment and identification of the source of infection.
D. Medical evaluation is essential for diagnosis and treatment, but before referral, the nurse must first assess exposure, symptoms, and potential risk factors to provide accurate information to the provider and prevent further spread.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Rationale:
A. While eye contact can indicate attentiveness, it does not confirm comprehension, especially when there is a language barrier. Cultural differences may also influence eye contact, making it an unreliable indicator of understanding.
B. The absence of questions does not guarantee understanding. Clients may hesitate to ask questions due to embarrassment, cultural norms, or lack of confidence, so this is not a reliable indicator of comprehension.
C. This demonstrates active engagement and accurate comprehension. Using printed materials or visual aids to indicate understanding shows the client can correctly identify or match information, which is a valid and observable indicator that the teaching has been understood.
D. Smiling or nodding may indicate politeness, attentiveness, or general agreement, but it does not confirm true understanding of the teaching content.
Correct Answer is A
Explanation
Rationale:
A. "What do others do for you that helps you the most?" is the most appropriate question to assess the client’s support systems. Support systems include family, friends, community resources, faith-based organizations, and other social networks that provide emotional, practical, or spiritual assistance during stressful events such as grief. Understanding the client’s support systems allows the nurse to: Identify who the client relies on for emotional comfort, guidance, and practical help, determine gaps in support that may require referral to social workers, grief counselors, or support groups, tailor interventions to enhance coping strategies, such as involving supportive family members in care or teaching stress management techniques and assess resilience factors that can buffer the negative effects of grief and promote psychological well-being.
B. "Have you thought about harming yourself?" is a safety assessment to identify suicidal ideation or risk for self-harm. While crucial for immediate safety, it does not provide information about the client’s social support network or resources for coping with grief.
C. "How long did you know the person who died?" explores the nature of the relationship and may help understand the intensity of grief, but it does not reveal who supports the client or how they cope.
D. "What are your hopes and plans for the future?" assesses the client’s long-term goals, outlook, and motivation, which can provide insight into resilience, but it does not identify available support systems or the practical and emotional assistance the client receives.
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