A community health nurse is evaluating eligibility for home assistance for a client who is quadriplegic. Which of the following actions should the nurse perform first?
Determine the client's living situation.
Problem solve with the client.
Offer community resources to the client.
Assist the client with decision-making
The Correct Answer is A
A. Determine the client's living situation: Assessing the client’s home environment is the first step in evaluating eligibility for home assistance. Understanding factors such as accessibility, caregiver support, and safety needs provides a foundation for planning appropriate interventions and resources tailored to the client’s circumstances.
B. Problem solve with the client: Problem-solving is an important part of care planning but should occur after the nurse has gathered essential information about the client’s living situation. Without this initial assessment, problem-solving may not address the client’s actual needs.
C. Offer community resources to the client: Providing information about resources is helpful but premature without first understanding the client’s living conditions and specific support requirements. This ensures recommendations are relevant and actionable.
D. Assist the client with decision-making: Supporting decision-making is crucial for client-centered care but comes after the nurse has assessed the client’s situation and presented appropriate options. Initial assessment informs safe and effective guidance.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. INR 1.1 (0.8 to 1.1): A normal INR indicates proper clotting function and does not increase risk for delayed wound healing. Coagulation status is adequate to support post-surgical recovery.
B. Hyperemesis: Persistent vomiting can lead to fluid and electrolyte imbalances, malnutrition, and protein depletion, all of which impair wound healing. Adequate nutrition is critical for collagen synthesis and tissue repair after surgery.
C. HbA1c 5.6% (4 to 5.9%): A normal HbA1c indicates good blood glucose control, which supports wound healing. Elevated blood glucose can impair healing, but this client’s level is within normal limits.
D. Uncontrolled pain: While uncontrolled pain can affect mobility and stress responses, it does not directly impair the physiological processes of wound healing. Pain management is important but less directly linked to delayed tissue repair than nutritional deficits.
Correct Answer is C
Explanation
A. Decrease intake of citrus foods and beverages: Citrus foods and beverages do not increase the risk of UTIs and may actually support general health through vitamin C. Restricting them is unnecessary and not part of standard UTI prevention education.
B. Wear nylon underwear: Nylon underwear is less breathable than cotton and can increase moisture, promoting bacterial growth. Clients should be advised to wear cotton underwear to reduce UTI risk.
C. Empty the bladder before and after intercourse: Urinating before and after sexual activity helps flush bacteria from the urethra, reducing the risk of infection. This is an effective and recommended preventive measure for clients with a history of UTIs.
D. Increase the time between voiding: Holding urine for extended periods allows bacteria to multiply in the urinary tract and increases the risk of infection. Clients should be advised to void regularly to prevent UTIs.
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