The nurse is preparing for an initial home care visit for a client with diabetes. Which action by the nurse is appropriate? SELECT ALL THAT APPLY
Asking how they are managing at home
Going automatically into the client's bedroom
Arranging mutual future visits
Thanking the client for arranging a home visit
Sitting down and discussing with the client and family members
Correct Answer : A,C,E
Choice A reason: Asking how they are managing at home is an appropriate action by the nurse. It shows respect and interest in the client's situation and helps to assess their needs, challenges, and goals.
Choice B reason: Going automatically into the client's bedroom is not an appropriate action by the nurse. It violates the client's privacy and autonomy and may make them feel uncomfortable or threatened. The nurse should ask for permission before entering any room in the client's home.
Choice C reason: Arranging mutual future visits is an appropriate action by the nurse. It demonstrates collaboration and commitment and helps to establish a trusting relationship with the client. It also allows the nurse to plan and coordinate the care and follow-up.
Choice D reason: Thanking the client for arranging a home visit is not an appropriate action by the nurse. It implies that the home visit is a favor or a burden, rather than a professional service that the client is entitled to. It may also undermine the nurse's authority and credibility.
Choice E reason: Sitting down and discussing with the client and family members is an appropriate action by the nurse. It indicates that the nurse values the client's perspective and input, and recognizes the family as an important source of support and information. It also facilitates communication and education and promotes shared decision-making.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["B","C"]
Explanation
Choice A reason: "I may experience urinary incontinence." This statement does not indicate the need for additional teaching. It is a correct statement that reflects an understanding of one of the possible symptoms of MS. Urinary incontinence is caused by nerve damage that affects bladder control.
Choice B reason: "I should not exercise because this may trigger an exacerbation." This statement indicates the need for additional teaching. It is an incorrect statement that reflects a misconception about exercise and MS. Exercise does not cause or worsen MS relapses but rather has many benefits for people with MS, such as improving muscle strength, balance, mobility, mood, and quality of life.
Choice C reason: "I should alternate the eye patch every other day to help with the double vision." This statement indicates the need for additional teaching. It is an incorrect statement that reflects a misunderstanding of how to manage double vision, which is another possible symptom of MS. Alternating the eye patch every other day does not help with double vision, but rather may cause eye fatigue or confusion. The correct way to use an eye patch is to wear it on one eye only when needed, such as when reading or driving.
Choice D reason: "I may experience visual disturbances." This statement does not indicate the need for additional teaching. It is a correct statement that reflects an awareness of another possible symptom of MS. Visual disturbances may include blurred vision, loss of color vision, pain in one eye, or partial or complete blindness.
Choice E reason: "I need to check the water temperature before I take a bath." This statement does not indicate the need for additional teaching. It is a correct statement that reflects a precaution that people with MS should take. Checking the water temperature before taking a bath can prevent burns or scalds, as some people with MS may have reduced sensation or numbness in their skin.
Correct Answer is A
Explanation
Choice A reason: Hypertension is a manifestation of increased intracranial pressure, as it reflects the body's attempt to maintain adequate cerebral perfusion pressure (CPP) and blood flow to the brain. CPP is the difference between the mean arterial pressure (MAP) and the intracranial pressure (ICP). When ICP rises, MAP must also rise to keep CPP constant and prevent cerebral ischemia. Hypertension is part of the Cushing's triad, which is a classic sign of increased ICP that also includes bradycardia and irregular respirations.
Choice B reason: Tinnitus is not a manifestation of increased intracranial pressure, as it does not affect the auditory system. Tinnitus is a ringing, buzzing, or hissing sound in the ears that can be caused by various factors, such as ear infections, noise exposure, medications, or aging. Tinnitus may be associated with other neurological conditions, such as Meniere's disease, acoustic neuroma, or multiple sclerosis, but not with increased ICP.
Choice C reason: Hypotension is not a manifestation of increased intracranial pressure, as it indicates a decrease in MAP and CPP, which can lead to cerebral ischemia and infarction. Hypotension can be caused by various factors, such as blood loss, dehydration, shock, or medications. Hypotension may worsen the outcome of increased ICP by reducing the oxygen and nutrient delivery to the brain.
Choice D reason: Tachycardia is not a manifestation of increased intracranial pressure, as it contradicts Cushing's triad. Tachycardia is an increase in heart rate that can be caused by various factors, such as anxiety, pain, fever, dehydration, or medications. Tachycardia may increase the oxygen demand and metabolic rate of the brain, which can exacerbate the effects of increased ICP.
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