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?
Discuss the benefits of eating a well-balanced diet with the client's family.
Assist the client and the client's partner with finding an affordable exercise program.
Offer to accompany the client and the client's partner during health care provider visits.
Ask family members about the impact of the disease on relationships within the family.
The Correct Answer is D
Choice A reason: Discussing the benefits of eating a well-balanced diet with the client's family is not the first action that the nurse should take. This is an important intervention that can help the client and the family to improve their nutrition and reduce the risk of further complications, but it should be done after the nurse has assessed the family's coping and learning needs.
Choice B reason: Assisting the client and the client's partner with finding an affordable exercise program is not the first action that the nurse should take. This is an important intervention that can help the client and the partner to increase their physical activity and enhance their cardiovascular health, but it should be done after the nurse has evaluated the client's physical and functional status.
Choice C reason: Offering to accompany the client and the client's partner during health care provider visits is not the first action that the nurse should take. This is an important intervention that can help the client and the partner to receive support and guidance during the treatment process, but it should be done after the nurse has established rapport and trust with the family.
Choice D reason: Asking family members about the impact of the disease on relationships within the family is the first action that the nurse should take. This is based on the principle of family-centered care, which states that the nurse should recognize and respect the family as the primary source of support and care for the client. The nurse should ask open-ended questions, listen actively, and express empathy to the family members, and explore how the disease has affected their roles, responsibilities, emotions, and communication.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A reason: A child who has a BMI of 18 is not the highest priority, as it is within the normal range for children. BMI, or body mass index, is a measure of weight relative to height. A BMI of 18 is considered healthy for children aged 2 to 20 years, according to the Centers for Disease Control and Prevention (CDC). The nurse should monitor the child's growth and development and provide nutrition education as needed.
Choice B reason: An adolescent who has scoliosis is not the highest priority, as it is a common and usually mild condition. Scoliosis is a sideways curvature of the spine that affects about 3% of adolescents. Most cases of scoliosis are mild and do not require treatment, although some may need braces or surgery. The nurse should refer the adolescent to a specialist for further evaluation and management.
Choice C reason: An adolescent who has psoriasis is not the highest priority, as it is a chronic and non-contagious condition. Psoriasis is a skin disorder that causes red, scaly patches on the skin that may itch or burn. Psoriasis is not curable, but it can be controlled with medications, creams, or light therapy. The nurse should provide education and support to the adolescent and encourage them to seek medical care as needed.
Choice D reason: A child who has nits is the highest priority, as it indicates a parasitic infestation that can spread to others. Nits are the eggs of head lice, which are tiny insects that live on the scalp and feed on blood. Head lice can cause itching, irritation, and infection of the scalp. The nurse should isolate the child and notify the parents and the school staff. The nurse should also provide instructions on how to treat the infestation and prevent reinfestation.
Correct Answer is D
Explanation
Choice A reason: Bradycardia is not a manifestation of alcohol withdrawal, but rather a sign of low heart rate. Alcohol withdrawal typically causes tachycardia, or high heart rate, as the body tries to compensate for the sudden absence of alcohol.
Choice B reason: Hypothermia is not a manifestation of alcohol withdrawal, but rather a sign of low body temperature. Alcohol withdrawal typically causes hyperthermia, or high body temperature, as the body reacts to the withdrawal symptoms.
Choice C reason: Increased appetite is not a manifestation of alcohol withdrawal, but rather a sign of hunger or craving. Alcohol withdrawal typically causes decreased appetite, or anorexia, as the body loses interest in food and suffers from nausea and vomiting.
Choice D reason: Insomnia is a manifestation of alcohol withdrawal, and one of the most common and distressing symptoms. Alcohol withdrawal causes insomnia, or difficulty falling or staying asleep, as the body experiences anxiety, agitation, and nightmares.
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