A home health nurse is conducting an initial home visit for a client who has terminal breast cancer. The client has two school-age children and a limited support system. Which of the following is the priority nursing action?
Inform the client of available community resources.
Assist the client in finding child care options.
Agree upon short-term goals for the client.
Ask the client about their understanding of the diagnosis.
The Correct Answer is D
A. Inform the client of available community resources is an important action because the client will likely need additional support, such as hospice care, counseling, or child care services. However, before providing resources, the nurse must assess the client’s understanding of their diagnosis to ensure any interventions are tailored to their current needs and readiness.
B. Assist the client in finding child care options - While important, addressing community resources takes precedence as it may encompass finding child care options as well.
C. Agree upon short-term goals for the client - Establishing goals is important but may come after addressing immediate needs.
D. Ask the client about their understanding of the diagnosis is the priority action. Before any other interventions, the nurse must assess the client’s knowledge and perception of their condition. This foundational step allows the nurse to provide appropriate education, clarify any misconceptions, and ensure that all care planning aligns with the client’s needs, values, and readiness to engage in discussions about their care.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Crepitus is a finding associated with subcutaneous emphysema or gas accumulation under the skin, typically not directly related to right ventricular heart failure.
B. Right ventricular heart failure can lead to increased pressure in the pulmonary artery, resulting in symptoms such as dyspnea, fatigue, and possibly right-sided heart murmurs.
C. Hepatosplenomegaly (enlargement of the liver and spleen) is more commonly associated with conditions such as liver cirrhosis, not specifically right ventricular heart failure.
D. Confusion is not typically associated with right ventricular heart failure unless there are complications such as hypoxemia or impaired cerebral perfusion.
Correct Answer is D
Explanation
A. Portable suction may be needed for some infants but is not specifically indicated for tetralogy of Fallot.
B. A cervical collar is used for neck support in patients with suspected cervical spine injuries and is not indicated for tetralogy of Fallot.
C. A hemodialyzer is used for renal replacement therapy and is not indicated for tetralogy of Fallot.
D. A pulse oximeter is essential for monitoring oxygen saturation levels in infants with tetralogy of Fallot, as they may experience cyanosis and hypoxemia. Monitoring oxygen saturation helps guide interventions and management.
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