A home health nurse is planning the initial home visit for a client who has dementia and lives with his adult son's family. Which of the following actions should the nurse take first during the visit?
Encourage the family to join a support group.
Provide the family with information about respite care.
Educate the family regarding the progression of dementia.
Engage the family in informal conversation.
The Correct Answer is D
Choice A reason: Encouraging the family to join a support group is not the first action that the nurse should take. This is an important intervention that can help the family cope with the challenges and stress of caring for a client who has dementia, but it should be done after the nurse has established rapport and trust with the family.
Choice B reason: Providing the family with information about respite care is not the first action that the nurse should take. This is an important intervention that can help the family access temporary relief from their caregiving responsibilities, but it should be done after the nurse has assessed the family's needs and preferences.
Choice C reason: Educating the family regarding the progression of dementia is not the first action that the nurse should take. This is an important intervention that can help the family understand the nature and course of the disease, and prepare them for the future changes and challenges, but it should be done after the nurse has evaluated the family's level of knowledge and readiness to learn.
Choice D reason: Engaging the family in informal conversation is the first action that the nurse should take. This is based on the principle of communication, which states that the nurse should initiate and maintain a therapeutic relationship with the client and the family. The nurse should use informal conversation to introduce herself, express interest and empathy, and create a comfortable and respectful atmosphere. The nurse should also use open-ended questions, active listening, and nonverbal cues to elicit the family's concerns, expectations, and goals.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason: Koplik spots are small, white, bluish-gray spots that appear on the inner cheeks, gums, or roof of the mouth before the rash develops. They are a characteristic sign of measles and can help to distinguish it from other viral infections.
Choice B reason: Persistent low-grade temperature is not a finding that the nurse should expect in a client who has measles. Measles typically causes a high fever that can reach up to 40°C (104°F) and lasts for four to seven days. The fever may spike when the rash appears and subside when the rash fades.
Choice C reason: Muscle aches and tenderness are not findings that the nurse should expect in a client who has measles. Measles mainly affects the respiratory system and the skin, and does not cause significant muscle involvement. The client may experience fatigue, weakness, or malaise, but not muscle pain or soreness.
Choice D reason: Rash confined to the trunk of the body is not a finding that the nurse should expect in a client who has measles. Measles causes a red, blotchy rash that usually starts on the face and spreads to the rest of the body, including the arms, legs, and feet. The rash may last for up to a week and may cause itching or peeling of the skin.
Correct Answer is C
Explanation
Choice A reason: Helping the client apply for Medicare is not the best action by the nurse, as Medicare is a federal health insurance program for people who are 65 or older, disabled, or have end-stage renal disease. The client does not meet any of these criteria and may not be eligible for Medicare.
Choice B reason: Exploring options for alternative therapies is not the best action by the nurse, as alternative therapies may not be effective or safe for treating tuberculosis. Tuberculosis is a serious bacterial infection that requires specific antibiotics to cure. Alternative therapies may also interfere with the prescribed medication or cause adverse effects.
Choice C reason: Arranging for medication through local agencies is the best action by the nurse, as it ensures that the client receives the appropriate treatment for tuberculosis. Local agencies may have programs or resources that can help the client access free or low-cost medication. The nurse should also educate the client about the importance of adhering to the medication regimen and completing the course of treatment.
Choice D reason: Sending the client to the nearest facility for further evaluation is not the best action by the nurse, as it may delay the initiation of treatment and increase the risk of transmission of tuberculosis to others. The client already has a diagnosis of tuberculosis and needs to start the treatment as soon as possible. The nurse should also advise the client to wear a mask and avoid close contact with others until the infection is no longer contagious.
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