A home health nurse is planning the initial home visit for a client who has dementia and lives with his adult son's family. Which of the following actions should the nurse take first during the visit?
Encourage the family to join a support group.
Provide the family with information about respite care.
Educate the family regarding the progression of dementia.
Engage the family in informal conversation.
The Correct Answer is D
Choice A reason: Encouraging the family to join a support group is not the first action that the nurse should take. This is an important intervention that can help the family cope with the challenges and stress of caring for a client who has dementia, but it should be done after the nurse has established rapport and trust with the family.
Choice B reason: Providing the family with information about respite care is not the first action that the nurse should take. This is an important intervention that can help the family access temporary relief from their caregiving responsibilities, but it should be done after the nurse has assessed the family's needs and preferences.
Choice C reason: Educating the family regarding the progression of dementia is not the first action that the nurse should take. This is an important intervention that can help the family understand the nature and course of the disease, and prepare them for the future changes and challenges, but it should be done after the nurse has evaluated the family's level of knowledge and readiness to learn.
Choice D reason: Engaging the family in informal conversation is the first action that the nurse should take. This is based on the principle of communication, which states that the nurse should initiate and maintain a therapeutic relationship with the client and the family. The nurse should use informal conversation to introduce herself, express interest and empathy, and create a comfortable and respectful atmosphere. The nurse should also use open-ended questions, active listening, and nonverbal cues to elicit the family's concerns, expectations, and goals.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason:This is a correct recommendation. The American Academy of Ophthalmology advises adults aged 40–64 to have a comprehensive eye exam every 2 years. Regular exams are essential to detect common age-related conditions like glaucoma, cataracts, and macular degeneration. After age 65, annual eye exams are often recommended.
Choice B reason: You should have your hearing screened every 10 years, not every 5 years, until the age of 50. After 50, you should have a hearing test every 3 years.
Choice C reason:While stool-based testing for colorectal cancer (such as FOBT or FIT) is recommended starting at age 45, it is typically done annually, not every other year. Other screening methods, like a colonoscopy, may have a longer interval but should follow guidelines tailored to the patient’s risk profile.
Choice D reason: You should have your fasting blood glucose level checked every 3 years, not every 6 years, starting at age 45. This is a screening test for diabetes, which can increase your risk of heart disease, stroke, kidney disease, and other complications. If you have a history of gestational diabetes, obesity, or other risk factors, you may need more frequent testing.
Correct Answer is D
Explanation
Choice A reason: Removing fresh flowers from the client's home is not an action that the nurse should take when caring for a client who has MRSA. Fresh flowers do not pose a risk of transmitting MRSA, and may provide some psychological benefits for the client.
Choice B reason: Wearing a mask when within 3 feet of the client is not an action that the nurse should take when caring for a client who has MRSA. MRSA is not an airborne infection, and a mask is not necessary to prevent its spread. The nurse should wear gloves and a gown when in contact with the client or the client's environment, and perform hand hygiene before and after the contact.
Choice C reason: Encouraging the client to use a HEPA filter in the house is not an action that the nurse should take when caring for a client who has MRSA. A HEPA filter is not effective in removing MRSA from the air, and may not have any impact on the client's health. The nurse should educate the client on how to clean and disinfect the surfaces and items that may be contaminated with MRSA, such as bedding, towels, and personal items.
Choice D reason: Double bagging soiled dressings in polyethylene bags is an action that the nurse should take when caring for a client who has MRSA. This is a standard precaution to prevent the exposure of other people or the environment to the infectious material. The nurse should also label the bags as biohazardous waste and dispose of them according to the agency's policy.
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