A community health nurse receives a referral for a family home visit. Which of the following tasks should the nurse perform first?
Clarify the source of the referral
Contact the family by phone
Implement the nursing process.
Schedule a time for the home visit
The Correct Answer is A
Rationale:
A. Clarify the source of the referral: Before taking any action, the nurse must first clarify the referral source to understand why the visit is needed, the client’s health status, and any specific concerns or priorities. This ensures the nurse has accurate and complete information to plan the visit safely and effectively.
B. Contact the family by phone: While contacting the family is necessary to arrange the visit, it should occur only after the nurse understands the purpose of the referral and any special considerations to communicate relevant information.
C. Implement the nursing process: Implementing the nursing process requires assessment and planning. The nurse cannot proceed to intervention without first obtaining information about the referral and preparing appropriately.
D. Schedule a time for the home visit: Scheduling is important for logistics, but it should occur after clarifying the referral and understanding the family’s needs to ensure the visit is purposeful and safe.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Rationale:
A. "My provider will make my health care decisions if I complete advance directives.": Advance directives are designed to communicate the client’s own wishes regarding medical care, not to give the provider decision-making authority. The client retains the right to guide their care through these legal documents.
B. "A living will is a document that includes my wishes about health care decisions.": This statement demonstrates understanding because a living will specifies the client’s preferences for medical treatments, such as resuscitation or life-sustaining measures, in the event they are unable to communicate their wishes.
C. "My partner needs to be present as a witness when I sign a living will.": Witness requirements vary by state, but typically a living will requires impartial adult witnesses, not necessarily a partner, to prevent conflicts of interest. Believing the partner must be present reflects a misunderstanding of legal requirements.
D. "Advance directives outline who inherits my material possessions in the event of my death.": This describes a will, not an advance directive. Advance directives pertain to medical care decisions, not the distribution of property or assets.
Correct Answer is D
Explanation
Rationale:
A. Administer a continuous infusion of calcium gluconate: Calcium gluconate is not used for the management of preeclampsia or seizure prophylaxis. Magnesium sulfate is the medication of choice to prevent eclamptic seizures in clients with severe preeclampsia.
B. Place the client in the semi-Fowler's position: Semi-Fowler’s position does not optimize uteroplacental perfusion. Left lateral positioning is preferred to enhance blood flow to the uterus and improve maternal and fetal oxygenation.
C. Ensure bright lighting in the room: Bright lighting can increase stimulation and anxiety, which is not beneficial for a client at risk for seizures. A calm, low-stimulation environment is preferable to minimize seizure triggers.
D. Initiate seizure precautions: Clients with preeclampsia with severe features are at high risk for eclampsia, making seizure precautions essential. These include placing the bed in a low position, padding side rails, having oxygen and suction available, and monitoring closely for neurologic changes.
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