On a repeat home visit to see an older adult widow, the nurse discovers that the client is unkempt, smells of stale urine, and does not recognize the neighbors or the nurse. Which action should the nurse take first?
Call the client's pharmacy to determine what medications she is taking.
Call Adult Protective Services to obtain emergency nursing home placement.
Complete a physical and mental exam of the client.
Seek the family's assistance in caring for the client.
The Correct Answer is C
Choice A reason: Reviewing medications may help identify causes of confusion or neglect, but it does not provide a full picture of the client’s current condition. It is a secondary step after direct assessment.
Choice B reason: Emergency placement may be necessary, but it should be based on a thorough assessment. Premature action without evaluation may violate the client’s rights or lead to inappropriate placement.
Choice C reason: A comprehensive physical and mental exam is essential to determine the cause of the client’s deterioration. It guides all subsequent decisions, including safety, medical needs, and potential referrals.
Choice D reason: Involving family may be helpful, but the nurse must first assess the client’s condition to determine the urgency and appropriateness of family involvement.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason: Arranging a meeting with the orchard manager is the most constructive and immediate step. It allows the nurse to address child labor concerns directly with those responsible for scheduling and oversight. This approach fosters collaboration and may lead to adjustments in work hours or responsibilities that prioritize the children's education and health. It also aligns with advocacy for vulnerable populations and respects the family's economic context while protecting the children’s rights.
Choice B reason: While health education is important, it does not address the root cause of the problem—excessive work hours interfering with sleep and school attendance. Education alone cannot resolve systemic labor issues or enforce child protection laws.
Choice C reason: Organizing focus groups may help gather parental perspectives, but it is a passive approach that delays action. It does not directly intervene in the labor practices affecting the children’s well-being.
Choice D reason: Notifying authorities may be necessary if abuse or neglect is suspected, but it should not be the first step unless there is clear evidence of legal violations. Premature reporting may damage trust and hinder future collaboration with the community.
Correct Answer is D
Explanation
Choice A reason: An A1C of 9.1% is significantly above the target range and indicates poor glycemic control. Congratulating the client would be inappropriate and misleading, potentially undermining the seriousness of the situation.
Choice B reason: While the value should be communicated to the healthcare provider, immediate reporting is not typically required unless the client is symptomatic or experiencing complications. The nurse’s role includes assessment and education before escalation.
Choice C reason: Asking the client why their A1C is out of control may come across as accusatory and lacks therapeutic communication. It does not foster collaboration or support behavior change. The nurse should use motivational interviewing and assessment techniques instead.
Choice D reason: Exploring the diabetes self-care regimen allows the nurse to identify gaps in medication adherence, dietary habits, physical activity, and glucose monitoring. This approach supports patient-centered care and enables tailored interventions to improve glycemic control.
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