A home health nurse is preparing to make an initial visit to a family following a referral from a local provider. Identify the sequence of steps the nurse should take when conducting a home visit. (Move the steps into the box on the right, placing them in the order of performance. Use all the steps.)
Record information about the home visit according to agency policy.
Contact the family to determine availability and readiness to make an appointment.
Discuss plans for future visits with the family.
Clarify the reason for the referral with the provider's office.
Identify family needs and interventions using the nursing process.
The Correct Answer is D,B,E,C,A
Rationale:
A. Record information about the home visit according to agency policy: Documentation is performed at the end of the visit to ensure that all observations, interventions, and plans are accurately recorded in the client’s record for continuity of care.
B. Contact the family to determine availability and readiness to make an appointment: Before visiting, the nurse should coordinate with the family to schedule a convenient time, ensuring that they are prepared for the assessment and intervention process.
C. Discuss plans for future visits with the family: After assessing the client and identifying needs, the nurse should collaborate with the family to plan ongoing visits and care strategies that align with their goals and availability.
D. Clarify the reason for the referral with the provider's office: This is the first step to ensure the nurse understands the purpose of the referral, specific concerns, and any important background information before contacting the family.
E. Identify family needs and interventions using the nursing process: During the visit, the nurse collects data, assesses needs, and develops appropriate interventions, forming the foundation for the care plan moving forward.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Patient-centered care: This competency focuses on respecting client preferences, values, and needs while involving them in care decisions. Completing an incident report does not directly address individualized client care.
B. Evidence-based practice: Evidence-based practice involves integrating the best current research evidence with clinical expertise and patient values. Documenting an incident report is not based on reviewing or applying research evidence.
C. Informatics: Informatics involves using information technology to communicate, manage knowledge, and support decision-making. While an incident report may use electronic systems, the primary purpose is not focused on informatics competency.
D. Quality improvement: Completing an incident report identifies errors, near misses, or adverse events, which helps the healthcare team analyze processes and implement changes to improve patient safety. This reflects the quality improvement competency by contributing to safer care systems.
Correct Answer is {"dropdown-group-1":"B","dropdown-group-2":"A"}
Explanation
Rationale for correct choices:
- Endoscopy: The client presents with a history of gnawing epigastric pain, one episode of dark, tarry stool, hypotension, tachycardia, and significant anemia. These findings suggest possible upper gastrointestinal bleeding or peptic ulcer disease. Endoscopy is the definitive diagnostic procedure to identify the source of bleeding and assess ulcer severity.
- Stool test results: The positive hemoccult (tarry stool) indicates gastrointestinal bleeding. This abnormal finding provides objective evidence that warrants further diagnostic evaluation through endoscopy to prevent further blood loss and complications.
Rationale for incorrect choices:
- Antibiotic prescription: While H. pylori infection can require antibiotics, this client’s immediate concern is gastrointestinal bleeding, not infection control. Antibiotics would not address the urgent need to identify and manage the bleeding source.
- Proton pump inhibitor therapy: Proton pump inhibitors help reduce gastric acid and promote ulcer healing, but initiating therapy alone does not evaluate or stop potential active bleeding. Endoscopy is needed first for diagnostic and possible therapeutic intervention.
- Hypotension: Although hypotension is present, it is a clinical sign of potential blood loss rather than a direct diagnostic criterion. It supports the urgency for endoscopy but is not the primary evidence for the procedure.
- Positive H. pylori test: While H. pylori infection contributes to ulcer formation, the acute presentation of bleeding evidenced by positive hemoccult stool makes the stool test a more immediate indicator for endoscopy.
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