Which assessment should the home health nurse include during a routine home visit for a client who was discharged home with a suprapubic catheter?

Choice A reason: Securing chest tube to the stretcher for transport is not the most important action for the nurse to take. Chest tube is a device that drains air or fluid from the pleural space or mediastinum after surgery or trauma. Securing chest tube to the stretcher can prevent accidental dislodgement or kinking of the tube during transport, but it is not as crucial as maintaining proper drainage.

Choice B reason: Marking the amount of chest drainage on the container is not the most important action for the nurse to take. Chest drainage is the fluid or air that collects in the chest tube container after being drained from the pleural space or mediastinum. Marking the amount of chest drainage on the container can help monitor fluid balance and detect excessive bleeding or leakage, but it is not as vital as ensuring proper drainage.

Choice C reason: This is the correct answer because keeping chest tube container below the site of insertion is the most important action for the nurse to take. Chest tube container is a device that collects air or fluid from the chest tube and maintains negative pressure in the pleural space or mediastinum. Keeping chest tube container below the site of insertion can prevent backflow of air or fluid into the chest cavity and maintain adequate drainage. If the chest tube container is raised above the site of insertion, it can cause tension pneumothorax, which is a life-threatening condition that occurs when air accumulates in the pleural space and compresses the lung and heart.

Choice D reason: Administering PRN pain medication prior to transport is not a timely action for the nurse to take. Pain medication is a drug that relieves pain by blocking pain signals or reducing inflammation. Administering pain medication prior to transport can improve comfort and reduce anxiety for the client, but it is not as urgent as preventing complications.

Choice A reason: A 16-year-old client diagnosed with major depression who refuses to participate in group does not require the nurse's immediate attention. Depression is a mood disorder that causes persistent feelings of sadness, hopelessness, and loss of interest. Refusing to participate in group may indicate low motivation, social withdrawal, or poor self-esteem, which are common symptoms of depression. The nurse should respect the client's preference and offer alternative activities or individual therapy.

Choice B reason: A 17-year-old client diagnosed with bipolar disorder who is pacing around the lobby does not require the nurse's immediate attention. Bipolar disorder is a mood disorder that causes alternating episodes of mania and depression. Pacing around the lobby may indicate restlessness, agitation, or increased energy, which are common signs of mania. The nurse should monitor the client's behavior and mood and ensure safety and appropriate medication administration.

Choice C reason: This is the correct answer because an 18-year-old client with antisocial behavior who is being yelled at by other clients requires the nurse's immediate attention. Antisocial behavior is a pattern of disregard for and violation of the rights of others. Being yelled at by other clients may indicate conflict, aggression, or provocation, which are common features of antisocial behavior. The nurse should intervene to de-escalate the situation and prevent violence or harm.

Choice D reason: A 14-year-old client with anorexia nervosa who is refusing to eat the evening snack does not require the nurse's immediate attention. Anorexia nervosa is an eating disorder that causes extreme restriction of food intake and fear of weight gain. Refusing to eat the evening snack may indicate distorted body image, dietary rules, or anxiety, which are common factors of anorexia nervosa. The nurse should encourage the client to eat and provide support and education.