An older client comes to the clinic with a family member. When the nurse attempts to take the client's health history, the client does not respond to questions in a clear manner. Which action should the nurse implement first?
Provide a printed health care assessment form.
Defer the health history until the client is less anxious.
Ask the family member to answer the questions.
Assess the surroundings for noise and distractions.
The Correct Answer is D
The ability to effectively communicate and provide accurate information can be impacted by external factors such as noise, distractions, or an unfamiliar environment. By assessing the surroundings, the nurse can identify and address any potential barriers to communication.
Once the nurse has addressed any environmental factors that may be hindering communication, they can proceed with other strategies to facilitate the health history assessment. This may include providing a printed healthcare assessment form to assist the client in organizing their thoughts or deferring the assessment until the client is less anxious.
Asking the family member to answer the questions should be considered if the client is unable to provide accurate information or is cognitively impaired. However, it is important to first address any environmental factors and attempt to engage the client directly in the assessment process.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Regular exercise is a vital component of managing type 2 diabetes. It helps to lower blood glucose levels, improve insulin sensitivity, and increase HDL (the "good" cholesterol) levels. However, it is important for the client to obtain medical approval before starting or modifying an exercise regimen. The healthcare provider can assess the client's overall health status and provide specific recommendations regarding the type, duration, and intensity of exercise suitable for the client's individual needs and any potential limitations.
Limiting calories on days unable to exercise is a valid strategy for managing weight and blood glucose levels; however, it is not specifically related to increasing HDL levels. It is important to maintain a balanced and healthy diet overall.
Monitoring blood glucose levels daily is an important self-care practice for individuals with diabetes, but it is not specifically focused on increasing HDL levels. Blood glucose monitoring helps to assess the effectiveness of diabetes management and make necessary adjustments to medication, diet, or exercise.
Monthly appointments with the dietitian can be beneficial for diabetes management, as dietary modifications play a significant role. However, the instruction regarding exercise is more directly related to increasing HDL levels, and the frequency of appointments with the dietitian may vary based on individual needs and goals.
Correct Answer is C
Explanation
A) Incorrect- While physical soothing can help comfort the child after the injections, it may not significantly reduce the duration of pain during the injections themselves.
B) Incorrect- Verbal reassurance is important to provide a calming environment, but it may not directly reduce the duration of pain during the injections.
C) Correct- Administering vaccines can be distressing for toddlers due to the pain associated with injections. To reduce the duration of pain and minimize the overall discomfort, the nurse should prioritize the strategy of simultaneous injections. This involves administering multiple vaccines at the same time rather than spacing them out. The rationale behind this approach is that the child experiences the discomfort of the injections only once, which can help reduce their overall distress and anxiety.
D) Incorrect- The positioning of the child may not have a direct impact on the duration of pain during injections. However, choosing an appropriate position for comfort is still important.
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