A nurse is caring for a client who has experienced a stroke and is moving in with their adult child.
Which of the following actions should the nurse encourage the client and family to take as they adjust to their new roles?
Implement firm but flexible boundaries in their relationship.
Minimize open discussion regarding the changes to avoid embarrassment.
Encourage authoritative communication from the adult child.
Decrease socialization with extended relatives until roles are identified.
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The Correct Answer is A
The correct answer is choice A. Implement firm but flexible boundaries in their relationship.
This is because boundaries can help the client and family to respect each other’s roles, needs and preferences, and to avoid role confusion, resentment or guilt. Boundaries can also promote independence and self-care for the client, as well as prevent caregiver burnout for the family.
Choice B is wrong because minimizing open discussion regarding the changes can lead to misunderstanding, frustration or isolation. The client and family should communicate openly and honestly about their feelings, expectations and challenges, and seek support when needed.
Choice C is wrong because authoritative communication from the adult child can create a power imbalance, undermine the client’s autonomy and dignity, or cause conflict or resistance. The client and family should use respectful and collaborative communication, and involve the client in decision-making as much as possible.
Choice D is wrong because decreasing socialization with extended relatives can reduce the client and family’s support network, increase their stress or loneliness, or limit their opportunities for meaningful activities. The client and family should maintain contact with their relatives and friends, and participate in social or recreational activities that they enjoy.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
The correct answer is choice B. Using an electronic messaging system to remind clients when to take medications. Tertiary prevention in healthcare involves measures taken to reduce the impact of an ongoing illness or injury that has lasting effects. This is done by helping people manage long-term, often-complex health problems and injuries in order to improve as much as possible their ability to function, their quality of life, and their life expectancy. In the context of an HIV clinic, reminding clients to take their medications can help manage the disease effectively and prevent complications.
Choice A rationale:
Educating clients about contraindications to specific immunizations is incorrect because this is more aligned with primary prevention, which aims to prevent the onset of an illness or injury before the disease process begins.
Choice C rationale:
Providing clients with information about the benefits of exercise is incorrect as this is generally considered a part of primary prevention, promoting general health to prevent various diseases.
Choice D rationale:
Helping clients understand health screenings covered by their insurance plans is incorrect because this is typically associated with secondary prevention, which involves screening to identify diseases in the earliest stages.
Correct Answer is D
Explanation
The correct answer is D. Remind the client to use the incentive spirometer.
Choice A rationale:
Observing the position of the suspended weight is beyond the scope of practice for assistive personnel (AP). This task requires assessment skills to ensure proper alignment and functioning of the traction system, which is the responsibility of the nurse.
Choice B rationale:
Checking the client’s pedal pulse on the right leg involves assessment and clinical judgment to evaluate perfusion and detect potential complications such as impaired circulation. This is not a task that can be delegated to AP.
Choice C rationale:
Asking the client to describe her pain requires assessment and interpretation of subjective data, which falls under the nurse's scope of practice. Pain assessment is a critical nursing function.
Choice D rationale:
Reminding the client to use the incentive spirometer is a non-assessment task that involves reinforcing previously taught instructions. This is appropriate to delegate to assistive personnel, as it does not require clinical judgment.
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