A homeless client arrives in the emergency room. The client verbalizes an inability to bathe for at least one month. What is the nurse's priority?
Inspect the client's skin
Provide a towel and show the client to the shower
Ask if the client has been to a homeless shelter recently
Call a social worker
The Correct Answer is A
Choice A reason: Inspecting the client's skin is the nurse's priority, because it is the most urgent and relevant action. Inspecting the client's skin can help identify any signs of infection, injury, or infestation, such as wounds, rashes, ulcers, or lice. The client's skin may be compromised by the lack of hygiene, exposure to the elements, or poor nutrition. The client's skin may also be a source of transmission of pathogens to other clients or staff. Therefore, inspecting the client's skin is essential for the assessment, diagnosis, and treatment of the client's condition.
Choice B reason: Providing a towel and showing the client to the shower is not the nurse's priority, because it is not the most urgent and relevant action. Providing a towel and showing the client to the shower is an important intervention, but it should be done after inspecting the client's skin and ensuring the safety and infection prevention of the client and others. The client may have wounds, rashes, or ulcers that need to be cleaned, dressed, or treated before bathing. The client may also have lice or scabies that need to be isolated and treated with special shampoos or creams before bathing. The client may also need assistance or supervision during bathing, depending on the client's physical and mental status.
Choice C reason: Asking if the client has been to a homeless shelter recently is not the nurse's priority, because it is not the most urgent and relevant action. Asking if the client has been to a homeless shelter recently is an important question, but it should be done after inspecting the client's skin and providing a towel and showing the client to the shower. The client's history of homelessness and shelter use may provide some information about the client's social and environmental factors, such as exposure to violence, abuse, or disease, or access to resources, services, or support. However, this information is not as critical as the client's skin condition, which may require immediate attention and care.
Choice D reason: Calling a social worker is not the nurse's priority, because it is not the most urgent and relevant action. Calling a social worker is an important referral, but it should be done after inspecting the client's skin, providing a towel and showing the client to the shower, and asking if the client has been to a homeless shelter recently. The social worker can help the client with the psychosocial and practical aspects of homelessness, such as finding a shelter, applying for benefits, accessing health care, or addressing mental health or substance abuse issues. However, this referral is not as urgent as the client's skin condition, which may require immediate attention and care.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason: Inflammatory is the phase of wound healing that occurs at the time of injury and lasts about 35 days, because it is the first and immediate response to tissue damage. Inflammatory is the phase of wound healing that involves the activation of the immune system, the release of chemical mediators, the dilation of blood vessels, the increase of blood flow, the migration of white blood cells, and the formation of a clot. Inflammatory is the phase of wound healing that aims to control bleeding, prevent infection, and prepare the wound for healing.
Choice B reason: Proliferative is not the phase of wound healing that occurs at the time of injury and lasts about 35 days, but rather the phase of wound healing that occurs after the inflammatory phase and lasts about 23 weeks. Proliferative is the phase of wound healing that involves the growth and multiplication of new cells, the formation of granulation tissue, the synthesis of collagen, the contraction of the wound edges, and the development of epithelial tissue. Proliferative is the phase of wound healing that aims to fill the wound, restore the strength, and cover the defect.
Choice C reason: Maturation is not the phase of wound healing that occurs at the time of injury and lasts about 35 days, but rather the phase of wound healing that occurs after the proliferative phase and lasts about several months to years. Maturation is the phase of wound healing that involves the remodeling and reorganization of the collagen fibers, the reduction of scar tissue, the improvement of elasticity, and the restoration of function. Maturation is the phase of wound healing that aims to refine the wound, enhance the quality, and optimize the outcome.
Choice D reason: Intentional is not the phase of wound healing that occurs at the time of injury and lasts about 35 days, but rather a classification of wound healing that depends on the type and extent of tissue damage, the degree of contamination, and the method of closure. Intentional is a classification of wound healing that refers to wounds that are surgically created, have minimal tissue loss, are clean and sterile, and are closed by primary intention, which means that the wound edges are approximated with sutures, staples, or glue. Intentional is a classification of wound healing that results in faster healing, less scarring, and lower risk of infection.
Correct Answer is B
Explanation
Choice A reason: This is an incorrect answer because a pathogenic infection is caused by a microorganism that can cause disease in a healthy host. Pathogens are usually able to overcome the host's immune defenses and cause symptoms and damage. Examples of pathogenic infections are strep throat, tuberculosis, and malaria.
Choice B reason: This is the correct answer because an opportunistic infection is caused by a microorganism that normally does not cause disease in a healthy host, but can take advantage of a weakened immune system and cause serious illness. Opportunistic infections are common and often lifethreatening complications of HIV infection, as the virus destroys the CD4 cells that help fight infections. Examples of opportunistic infections are pneumocystis pneumonia, candidiasis, and toxoplasmosis.
Choice C reason: This is an incorrect answer because a nosocomial infection is acquired in a health care setting, such as a hospital, clinic, or nursing home. Nosocomial infections are usually caused by microorganisms that are resistant to antibiotics and can spread easily among patients and staff. Examples of nosocomial infections are methicillinresistant Staphylococcus aureus (MRSA), Clostridioides difficile (C. diff), and urinary tract infections.
Choice D reason: This is an incorrect answer because a root cause infection is not a valid term in medical terminology. A root cause is the underlying factor or reason that leads to a problem or outcome. A root cause analysis is a process of identifying and addressing the root causes of a problem or event, such as an infection, to prevent recurrence and improve quality and safety.
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