An older client tells the home health care practical nurse (PN) about experiencing dizziness when getting out of bed. Which assessment is most important for the PN to obtain?

A. Explain daily schedule of unit activities: Introducing the unit’s schedule too early may overwhelm a paranoid client who is already fearful and withdrawn. The client first needs to establish a sense of safety and trust before being able to process details about daily routines.

B. Offer the client an as needed (PRN) medication: Administering medication without assessing the client’s readiness to communicate or identifying signs of distress is premature. PRN medications should only be offered when clinically indicated and after therapeutic approaches have been attempted.

C. Describe functions of the practical nurse (PN): Explaining the PN’s role is the best initial action because it reduces the client’s anxiety and suspicion. Paranoid clients often feel threatened by unfamiliar individuals, so calmly explaining your role helps establish trust, clarify intent, and promote engagement in care.

D. Review client rights of hospitalization: Although reviewing client rights is important, it is not the priority when first approaching a paranoid client. Discussing rights before rapport is established may be perceived as intimidating or confusing, further increasing the client’s withdrawal or fear.

A. Confirm accuracy of the pulse rate obtained by the UAP: Verifying the rate ensures accuracy but does not address an error in technique. If the UAP is using an incorrect location or method, the pulse reading may be unreliable even if counted correctly.

B. Instruct the UAP to report any abnormal findings: While reporting abnormal findings is an essential part of delegation, this instruction assumes the UAP is performing the skill correctly. The nurse must first ensure that the UAP understands proper technique before emphasizing reporting.

C. Demonstrate the correct pulse site to the UAP: The practical nurse should demonstrate the correct placement of fingers over the radial artery to ensure accurate assessment. Teaching proper technique prevents future errors, promotes competency, and upholds patient safety.

D. Remind the UAP to check the client's pulse volume: Assessing pulse volume is an important observation, but if the pulse site is incorrect, the measurement will not be valid. Correct technique must be established before refining assessment details such as volume.