A home health nurse is reviewing messages from a group of clients. Which of the following clients should the nurse contact first?
A mother who reports that her son vomited after a dose of methylphenidate
A client who has COPD and reports an oxygen saturation of 90%
A client who reports that her new colostomy stoma appears purple
A client who reports feeling a vibration in his new internal arteriovenous graft for dialysis
The Correct Answer is C
The mother reporting vomiting in choice A may be concerning, but it is a known side effect of methylphenidate, and the client should be monitored for any further symptoms. A client who has COPD and reports an oxygen saturation of 90%. An oxygen saturation of 90% in COPD is within normal due to the chronic hypoxia.The purple appearance of a colostomy stoma in choice C may indicate ischemia or necrosis, and is an urgent concern.The feeling of a vibration in a new arteriovenous graft for dialysis in choice D may indicate an arterial steal syndrome, but it is not a medical emergency, and the client can be instructed to follow up with the provider. Therefore, the correct answer is choice B.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
The nurse should determine how the adolescent's health has affected family roles and responsibilities to identify areas where the family may need assistance. Directing the conversation solely to the parents or focusing on the adolescent's future career plans is not appropriate as it may exclude the adolescent from the discussion. Asking another family to attend the meeting is not necessary unless the family requests it.
Correct Answer is D
Explanation
The correct answer is Choice D because "Explore possible solutions with the partner." When a hospice nurse is concerned that the partner of a client is experiencing caregiver burden, the first step is to explore possible solutions with the partner. This involves assessing the partner's needs, concerns, and limitations, and working collaboratively to develop a plan of care that meets the needs of both the client and the partner. This may involve arranging for additional support, such as respite care or home health services, or modifying the care plan to make it more manageable for the partner.
Choice A is wrong because Suggesting assistive personnel visits daily to provide client care (Choice A is wrong because) may provide additional support, but it does not address the partner's caregiver burden.
Choice B is wrong because Teaching the partner about getting enough rest (Choice B is wrong because) may be helpful, but it does not address the underlying caregiver burden and may be perceived as dismissive of the partner's concerns.
Choice C is wrong because Encouraging the partner to invite family members to assist with client care (Choice C is wrong because) may provide additional support, but it assumes that the partner has family members who are available and willing to assist and does not address the underlying caregiver burden.
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