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.

Answer and Explanation

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.

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Correct Answer is D

Explanation

A. A head circumference 1 cm greater than the chest is within normal variations and does not typically require immediate notification.

B. A positive Babinski reflex is a normal finding in newborns and does not warrant immediate notification.

C. Passage of meconium stool within the first 24 hours of life is considered normal and does not require notification.

D. The pinna (ear) below the outer canthus of the eye can indicate a condition called low-set ears, which may be associated with genetic syndromes or other abnormalities. This finding warrants notification to the provider for further evaluation.

A. A client who is at 38 weeks of gestation and reports irregular uterine contractions B. A client who is at 39 weeks of gestation and is scheduled for a weekly nonstress test (NST) C. A client who is at 40 weeks of gestation and is scheduled for an induction of labor D. A client who is at 36 weeks of gestation and reports decreased fetal movement for 2 days

Correct Answer is D

Explanation

A. Irregular uterine contractions at 38 weeks of gestation may not be a concern unless they become regular and more intense.

B. A client scheduled for a nonstress test (NST) at 39 weeks of gestation can typically wait until after attending to more urgent matters.

C. A client scheduled for an induction of labor at 40 weeks of gestation is not necessarily a priority unless there are urgent concerns.

D. Decreased fetal movement, especially for 2 days at 36 weeks of gestation, requires immediate assessment to ensure fetal well-being.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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