A parish nurse is counseling a family following a client's recent diagnosis of heart disease.
Which of the following actions should the nurse take first?
Assist the client and the client's partner with finding an affordable exercise program.
Discuss the benefits of eating a well-balanced diet with the client's family.
Ask family members about the impact of the disease on relationships within the family.
Offer to accompany the client and the client's partner during health care provider visits.
The Correct Answer is C
Choice A rationale
While finding an affordable exercise program is an important intervention, it is a part of the long-term management of heart disease. It does not address the immediate emotional and relational impact of the diagnosis on the family system, which must be understood first to provide effective, holistic care.
Choice B rationale
Discussing the benefits of a well-balanced diet is a key component of health education for heart disease. However, without first assessing the family's understanding and emotional response to the diagnosis, this discussion may not be well-received or acted upon, as it is not the most immediate priority.
Choice C rationale
This is the correct action to take first as it addresses the immediate emotional and psychological impact of the diagnosis on the family. The nurse must first understand how the diagnosis is affecting family relationships and dynamics before providing any other interventions, as this assessment provides the foundation for holistic and client-centered care.
Choice D rationale
Offering to accompany the client to a doctor’s appointment is a supportive action. However, it is a subsequent intervention that can be offered after the nurse has assessed the family's immediate needs and emotional reactions. It is not the initial priority, which is to assess the family's perspective and feelings about the diagnosis.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale
Advising a client to wait until their children start school to catch up on immunizations is scientifically incorrect and places the children at unnecessary risk for vaccine-preventable diseases. The goal of immunizations is to provide protection early in life, and delaying them increases the period of susceptibility. A catch-up schedule should be initiated as soon as possible to ensure timely immunity.
Choice B rationale
Contacting the agency pharmacist is not the most appropriate action for a nurse. While pharmacists are knowledgeable, the most reliable and scientifically validated source for immunization schedules and guidelines is the Centers for Disease Control and Prevention (CDC). A nurse should use the most current and evidence-based information directly from the authoritative source to ensure accuracy and patient safety.
Choice C rationale
Informing the client that their children need to restart the entire immunization series is inaccurate information. The CDC's catch-up schedule clearly states that it is not necessary to restart a series if it has been interrupted. A nurse should provide accurate, evidence-based information, and restarting the series would be an unnecessary burden and potential waste of resources.
Choice D rationale
Accessing the CDC website is the most scientifically sound action. The CDC is the primary federal public health agency in the United States and maintains the official, evidence-based, and regularly updated immunization schedules, including specific guidelines for children who are behind. This action ensures the nurse provides accurate and current information to the client.
Correct Answer is B
Explanation
Choice A rationale
Applying antibiotic ointment is a standard and safe prescription for a surgical wound to prevent infection. The prescription is appropriate and does not need to be verified with the provider, as it is consistent with the standard of care for postoperative wound management. It promotes wound healing and reduces the risk of bacterial contamination.
Choice B rationale
Soaking the feet in warm water is contraindicated for a diabetic client due to the high risk of burns and maceration of the skin, which can lead to infection and non-healing ulcers. Diabetic neuropathy often impairs sensation, so the client may not be able to detect excessively hot water, causing significant tissue damage. This prescription must be verified immediately.
Choice C rationale
Teaching the client how to inspect their feet daily is a crucial aspect of diabetic foot care. Daily inspection helps in the early detection of cuts, blisters, and other injuries that could lead to serious infections. This instruction is a necessary and standard component of a diabetic foot care plan and does not require verification.
Choice D rationale
Following up with a podiatrist is a standard and essential component of care for a client with diabetes who has had a foot procedure. Podiatrists specialize in foot health and can provide ongoing care, specialized trimming of nails, and monitoring for complications. This prescription is appropriate and promotes long-term foot health and requires no verification.
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