The nurse is caring for a client that fell at home and is planning to move in with their adult child. Which of the following statements, by the client, would require immediate follow up by the nurse?

"I will try to make myself useful while I am in their home."

"My adult child has been preparing my grandchildren for my arrival."

"I will miss my home that I lived in for so long."

"My other adult child is willing to help me too."

Answer and Explanation

The Correct Answer is C

A. "I will try to make myself useful while I am in their home." This statement reflects a positive attitude and willingness to contribute, which does not require immediate follow-up.

B. "My adult child has been preparing my grandchildren for my arrival." This statement indicates that preparations are being made, which is generally a good sign and does not require immediate follow-up.

C. "I will miss my home that I lived in for so long." This statement requires immediate follow-up because it may indicate emotional distress or difficulty adjusting to the new living situation. The nurse should assess the client’s feelings and provide support to help them cope with the transition.

D. "My other adult child is willing to help me too." This statement is positive and indicates additional support, which is generally reassuring and does not require immediate follow-up.

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Correct Answer is A

Explanation

A. "Can you describe the feeling you are experiencing?" Asking the patient to describe their sensation helps identify the nature of their discomfort and guides appropriate pain management or further investigation.

B. "Would you like me to give you some pain medication?" Offering pain medication may address the discomfort, but it is important to first understand the nature and severity of the pain.

C. "Do you feel better sitting in the chair?" This question assesses the patient’s comfort but does not address the cause of the pain or discomfort.

D. "Let me know if you are still uncomfortable in the chair." This is a follow-up question rather than an initial assessment, and it may not be proactive enough in addressing the cause of pain.

A. "I can tell your family not to visit you close to bedtime." B. "Would you like me to provide you with earplugs?" C. "I can get you a mental health consult if you think that would help." D. "Tell me why you think you may not be sleeping at night."

Correct Answer is D

Explanation

A. "I can tell your family not to visit you close to bedtime." While this could be a consideration, it does not address the patient's immediate concerns and the possible causes of their sleep issues.

B. "Would you like me to provide you with earplugs?" This is a possible solution but does not investigate the underlying cause of the sleep issue.

C. "I can get you a mental health consult if you think that would help." A mental health consult may be helpful, but it is not the first step in understanding and addressing the immediate concern.

D. "Tell me why you think you may not be sleeping at night." This is the best initial response as it allows the nurse to understand the root cause of the patient's sleep disturbances and address specific issues, such as noise, light, or discomfort.

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The nurse is caring for a client that fell at home and is planning to move in with their adult child. Which of the following statements, by the client, would require immediate follow up by the nurse?

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Naxlex Comprehensive Predictor Exams

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