A home health nurse is scheduled for a first time visit to a client. Which of the following should the nurse perform first?
Blood pressure screening
Mental status examination
Review of the neighborhood
Family history
The Correct Answer is C
Choice A reason: Blood pressure screening is not the first thing that the nurse should perform, as it is a physical assessment that can be done later in the visit. Blood pressure screening is important to monitor the client's cardiovascular health and risk of hypertension, but it is not a priority for the initial visit.
Choice B reason: Mental status examination is not the first thing that the nurse should perform, as it is a psychological assessment that can be done later in the visit. Mental status examination is important to evaluate the client's cognitive, emotional, and behavioral functioning and identify any mental health issues, but it is not a priority for the initial visit.
Choice C reason: Review of the neighborhood is the first thing that the nurse should perform, as it is an environmental assessment that can provide valuable information about the client's living conditions, safety, and resources. Review of the neighborhood is important to identify any potential hazards, barriers, or needs that may affect the client's health and well-being, and to plan appropriate interventions and referrals.
Choice D reason: Family history is not the first thing that the nurse should perform, as it is a genetic and social assessment that can be done later in the visit. Family history is important to determine the client's risk of inheriting or developing certain diseases, and to understand the client's family dynamics and support system, but it is not a priority for the initial visit.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A reason: Asking the client if they have been thinking about harming themselves is not the best response, as it may sound accusatory or judgmental. It may also make the client defensive or reluctant to share their feelings. The nurse should assess the client's suicide risk later, after establishing rapport and trust.
Choice B reason: Asking the client how long they have been feeling this way is not the most appropriate response, as it may imply that the nurse is more interested in the duration of the problem than the client's current situation. It may also suggest that the nurse expects the client to have a clear timeline of their feelings, which may not be the case.
Choice C reason: Telling the client to share what is going on with them right now is the best response, as it shows empathy and genuine interest in the client's perspective. It also invites the client to express their thoughts and emotions, and helps the nurse identify the factors that contribute to the client's sense of meaninglessness.
Choice D reason: Asking the client if they really think their life has no purpose is not a helpful response, as it may sound dismissive or sarcastic. It may also make the client feel invalidated or misunderstood, and reinforce their negative beliefs. The nurse should avoid challenging the client's statements, and instead explore the reasons behind them.
Correct Answer is D
Explanation
Choice A reason: Encouraging the family to join a support group is not the first action that the nurse should take. This is an important intervention that can help the family cope with the challenges and stress of caring for a client who has dementia, but it should be done after the nurse has established rapport and trust with the family.
Choice B reason: Providing the family with information about respite care is not the first action that the nurse should take. This is an important intervention that can help the family access temporary relief from their caregiving responsibilities, but it should be done after the nurse has assessed the family's needs and preferences.
Choice C reason: Educating the family regarding the progression of dementia is not the first action that the nurse should take. This is an important intervention that can help the family understand the nature and course of the disease, and prepare them for the future changes and challenges, but it should be done after the nurse has evaluated the family's level of knowledge and readiness to learn.
Choice D reason: Engaging the family in informal conversation is the first action that the nurse should take. This is based on the principle of communication, which states that the nurse should initiate and maintain a therapeutic relationship with the client and the family. The nurse should use informal conversation to introduce herself, express interest and empathy, and create a comfortable and respectful atmosphere. The nurse should also use open-ended questions, active listening, and nonverbal cues to elicit the family's concerns, expectations, and goals.
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