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 B
Explanation
Choice A reason: Demographics is not the priority information for the community health nurse to obtain from each client, as it is not directly related to the transmission or treatment of tuberculosis. Demographics is the statistical data of a population, such as age, gender, race, or income. The nurse may collect this information for surveillance or research purposes, but it is not essential for the immediate care of the client.
Choice B reason: Household members is the priority information for the community health nurse to obtain from each client, as it is crucial for the prevention and control of tuberculosis. Household members are the people who live with or share the same living space with the client. They are at high risk of being exposed to or infected with tuberculosis, as the disease is spread through respiratory droplets from coughing or sneezing. The nurse should identify and screen the household members for tuberculosis, and provide them with prophylactic antibiotics if needed.
Choice C reason: Occupation is not the priority information for the community health nurse to obtain from each client, as it is not directly related to the transmission or treatment of tuberculosis. Occupation is the type of work or profession that the client does. The nurse may collect this information for occupational health or social support purposes, but it is not essential for the immediate care of the client.
Choice D reason: Health history is not the priority information for the community health nurse to obtain from each client, as it is not directly related to the transmission or treatment of tuberculosis. Health history is the record of the client's past and present medical conditions, medications, allergies, or surgeries. The nurse may collect this information for diagnosis or management purposes, but it is not essential for the immediate care of the client.
Correct Answer is B
Explanation
Choice A reason: A humidifier should be placed beside the child's bed is not the information that the nurse should include, as it is not relevant to pertussis. Pertussis, or whooping cough, is a bacterial infection that causes severe coughing spells, difficulty breathing, and a characteristic whooping sound. A humidifier may help with other respiratory conditions, such as bronchitis or asthma, but it does not affect pertussis.
Choice B reason: Household contacts will receive prophylactic antibiotics is the information that the nurse should include, as it is an important measure to prevent the spread of pertussis. Pertussis is highly contagious and can be transmitted through respiratory droplets from coughing or sneezing. Household contacts, especially those who are not fully vaccinated or have a weakened immune system, are at risk of contracting pertussis from the child. Prophylactic antibiotics, such as azithromycin or erythromycin, can reduce the risk of infection and complications.
Choice C reason: Transmission will be prevented because of herd immunity is not the information that the nurse should include, as it is not true for pertussis. Herd immunity is the protection that occurs when a large proportion of the population is immune to a disease, either through vaccination or natural infection. Herd immunity can reduce the transmission of some diseases, such as measles or polio, but it is not effective for pertussis. This is because pertussis immunity wanes over time, and the current vaccines do not provide long-lasting protection. Therefore, even vaccinated people can get or spread pertussis.
Choice D reason: The child is most contagious after the rash develops is not the information that the nurse should include, as it is not true for pertussis. Pertussis does not cause a rash, unlike some other childhood diseases, such as measles or chickenpox. The child is most contagious during the first two weeks of the illness, when the symptoms are similar to a common cold. The coughing spells usually start after the first week and can last for several weeks or months.
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