A home health nurse is visiting a client who has right-sided weakness following a recent stroke. The client states, "I'm not sure how I will buy my groceries since I can't go back to work." Which of the following actions should the nurse take?
Offer to bring groceries to the client on a regular basis.
Initiate a referral for the client to a social worker.
Contact friends and neighbors to shop for the client.
Provide the client information about respite care.
The Correct Answer is B
The correct answer is choice B, Initiate a referral for the client to a social worker.
Explanation: The nurse should initiate a referral for the client to a social worker who can assist with financial and social issues related to the client's disability.
Offering to bring groceries to the client or contacting friends and neighbors are not sustainable long-term solutions. Providing information about respite care is not relevant to the client's immediate concern.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
The correct answer is Choice A because, "I am obese because it's in my genes." The client is using rationalization as a coping mechanism by justifying their obesity as being predetermined by their genes, rather than acknowledging their personal responsibility in managing their weight. Rationalization is a defense mechanism in which a person gives a false or socially acceptable explanation for an unacceptable behavior or situation.
Choice B is wrong because, "I have difficulty resisting the items in vending machines," is not the correct answer because it is an excuse rather than a rationalization.
Choice C is wrong because, "I know you don't like me because I am obese," is not the correct answer because it is an example of projection, in which the client attributes their own feelings of dislike to others.
Choice D is wrong because, "I have lots of health problems from being obese," is not the correct answer because it is a justification, not a rationalization
Correct Answer is C
Explanation
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.
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