An older client comes to the clinic with a family member. When the nurse attempts to take the client's health history, the client does not respond to questions in a clear manner. Which action should the nurse implement first?
Provide a printed health care assessment form.
Defer the health history until the client is less anxious.
Ask the family member to answer the questions.
Assess the surroundings for noise and distractions.
The Correct Answer is D
The ability to effectively communicate and provide accurate information can be impacted by external factors such as noise, distractions, or an unfamiliar environment. By assessing the surroundings, the nurse can identify and address any potential barriers to communication.
Once the nurse has addressed any environmental factors that may be hindering communication, they can proceed with other strategies to facilitate the health history assessment. This may include providing a printed healthcare assessment form to assist the client in organizing their thoughts or deferring the assessment until the client is less anxious.
Asking the family member to answer the questions should be considered if the client is unable to provide accurate information or is cognitively impaired. However, it is important to first address any environmental factors and attempt to engage the client directly in the assessment process.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A) Incorrect - While a salad includes vegetables and fruits, it may not provide sufficient protein for wound healing.
B) Incorrect - Vegetable soup and crackers might not provide enough protein compared to other options.
C) Incorrect - While a peanut butter sandwich includes some protein, soda and cookies are not rich sources of protein.
D) Correct- A tuna fish sandwich is a good source of protein. Protein is essential for wound healing as it supports tissue repair and regeneration. The choice of a tuna fish sandwich along with chips and ice cream suggests a balanced meal with adequate protein content, which aligns with the teaching of a high protein diet to promote wound healing.
Correct Answer is D
Explanation
A) Incorrect- Observing for swelling at the fracture site is important for assessing the client's musculoskeletal condition, but it is not the priority intervention in this situation. The absence of spontaneous respirations and palpable carotid pulse indicates cardiac arrest, and immediate intervention is needed.
B) Incorrect- Analyzing the cardiac rhythm in another lead is not the first priority when the client is in cardiac arrest. Cardiopulmonary resuscitation (CPR) should be initiated immediately to restore circulation.
C) Incorrect- Obtaining a 12-lead electrocardiogram is not the initial intervention in a client in cardiac arrest. CPR and defibrillation (if indicated) are the immediate actions to provide circulation and oxygenation to the vital organs.
D) Correct- The absence of spontaneous respirations and palpable carotid pulse indicates cardiac arrest. In this situation, immediate initiation of cardiopulmonary resuscitation (CPR) is critical to provide circulation and oxygenation to the vital organs. Chest compressions are the initial step to address cardiac arrest and ensure blood flow to the body.
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