A home health nurse is visiting a client who has a new diagnosis of diabetes mellitus. Which of the following actions should the nurse take first?
Teach the client about appropriate food choices.
Refer the client to a diabetes mellitus support group.
Identify the client's dietary preferences.
Develop a nutritional program.
The Correct Answer is C
Choice A reason: Teaching the client about appropriate food choices is an important intervention for diabetes mellitus, but it is not the first action the nurse should take. The nurse needs to assess the client's current dietary habits and preferences before providing education.
Choice B reason: Referring the client to a diabetes mellitus support group is a helpful strategy to promote coping and self-management, but it is not the first action the nurse should take. The nurse needs to address the client's immediate needs and priorities before making referrals.
Choice C reason: Identifying the client's dietary preferences is the first action the nurse should take. This is an assessment step that will help the nurse tailor the nutritional program to the client's individual needs and preferences. It will also help the nurse establish rapport and trust with the client.
Choice D reason: Developing a nutritional program is a planning step that requires assessment data. The nurse should not develop a nutritional program without first identifying the client's dietary preferences and needs.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason: The child has recent onset of urinary incontinence is a possible sign of maltreatment, as it may indicate sexual abuse, emotional trauma, or neglect. The school nurse should report this finding to the child protective services and follow up with the child and the family¹².
Choice B reason: The child receives free lunches at school is not a sign of maltreatment, but rather a socioeconomic indicator. The school nurse should not assume that the child is maltreated based on this factor alone, but rather assess the child for other signs and symptoms of abuse or neglect³.
Choice C reason: The child has bruises on both knees is not a sign of maltreatment, but rather a common injury among children who are active and playful. The school nurse should not report this finding unless there are other suspicious circumstances, such as inconsistent explanations, unusual locations, or patterns of bruises⁴.
Choice D reason: The child reports having a toothache is not a sign of maltreatment, but rather a health issue that may require dental care. The school nurse should not report this finding unless there are other signs of neglect, such as poor oral hygiene, lack of access to health care, or failure to follow up on referrals⁵.
Correct Answer is B
Explanation
Choice A reason: This statement is not the best action, as it may violate the adolescent's and the family's right to privacy and confidentiality. The nurse should only share the adolescent's diagnosis with the consent of the adolescent and the family, and only with those who need to know.
Choice B reason: This statement is the best action, as it demonstrates the nurse's role as a counselor and advocate for the family. The nurse should assess the family's needs for support or guidance, as they may be experiencing stress, anxiety, or grief related to the adolescent's illness.
Choice C reason: This statement is not the best action, as it may not address the family's emotional or spiritual needs. The nurse should refer the family to the adolescent's health care providers only if they have questions or concerns about the medical aspects of the adolescent's care.
Choice D reason: This statement is not the best action, as it may not be appropriate or relevant for the family. The nurse should review the adolescent's care plans with the family only if they are involved in the adolescent's care or if the adolescent and the family request it.
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