A nurse is completing the intake health assessment at a clinic. Which of the following is the priority action for the nurse to take?
Ensure that the client has filled out a release of information form from their previous primary care provider.
Document allergies in the electronic medical record.
Getting a list of all medications that have been prescribed to the client.
Ask the client what the biggest concern is at this time.
The Correct Answer is D
Identifying the client's primary health issue or reason for seeking care, the nurse can prioritize the assessment and subsequent care interventions accordingly. This approach ensures that urgent or important health issues are addressed promptly, contributing to patient safety and satisfaction.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Caring for diverse clients will require balancing differences and needs acknowledges the importance of recognizing and respecting cultural diversity among clients. Each individual may have unique cultural backgrounds, beliefs, values, and needs. The nurse must balance these differences effectively to provide care that is sensitive to each client's cultural context.
B. It assumes homogeneity among individuals within the same neighborhood, disregarding the reality of cultural diversity even within small geographic areas.
C. It suggests that all clients, regardless of cultural background, should receive the same standard of care.
D. It disregards the importance of considering clients' cultural diversity in developing the plan of care.
Correct Answer is ["C","D","E"]
Explanation
A. In cases of dehydration, urine output may decrease, resulting in a more concentrated urine that appears darker in color. Therefore, the nurse may expect the urine to be darker in color.
B. Tachycardia is more commonly observed due to dehydration and the body's compensatory mechanisms.
C. Poor skin turgor is a classic sign of dehydration and may be observed in clients with vomiting and diarrhea.
D. Flat neck veins aretypically associated with dehydration. This occurs due to reduced intravascular volume leading to collapse of the veins.
E. Hypotension is commonly associated with dehydration resulting from vomiting and diarrhea. Loss of fluids and electrolytes can lead to decreased blood volume and subsequent hypotension.
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