When visiting a client's home, which action should the nurse take to ensure personal safety and respect the client's household values?
Always carry personal protective equipment in a visible manner.
Always start the visit by discussing the client's medical history.
Request the client to leave the room during the nurse's assessment.
Ask for permission before entering each room in the home.
The Correct Answer is D
A. Always carry personal protective equipment in a visible manner: While PPE is important for infection control, displaying it prominently may create fear or imply mistrust. PPE should be used appropriately without compromising rapport or household comfort.
B. Always start the visit by discussing the client's medical history: Beginning with medical history may overlook establishing rapport and respecting the client’s household norms. Initial engagement should prioritize trust, cultural sensitivity, and comfort before detailed health discussions.
C. Request the client to leave the room during the nurse's assessment: Asking the client to leave is unnecessary and may be perceived as disrespectful or intrusive. Assessments should involve the client when appropriate, maintaining privacy and dignity without excluding them unnecessarily.
D. Ask for permission before entering each room in the home: Seeking permission demonstrates respect for the client’s privacy, personal space, and household values. It establishes trust, supports safety, and aligns with culturally sensitive, patient-centered care practices.
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Related Questions
Correct Answer is D
Explanation
A. Objective: Objective data consist of measurable or observable findings such as vital signs, physical exam results, or diagnostic data. Headache and dizziness cannot be directly measured by the nurse and rely on the patient’s description. These findings do not belong in the objective section.
B. Plan: The plan section outlines intended nursing interventions, treatments, or follow-up actions based on assessment findings. Patient-reported symptoms are used to guide planning but are not documented within this section. The plan focuses on what will be done, not what the patient feels.
C. Evaluation: Evaluation documents the patient’s response to interventions and whether outcomes were achieved. Headache and dizziness may be reassessed later in this section after treatment. Initial symptom reporting does not fit evaluation charting.
D. Subjective: Subjective data include symptoms and experiences reported directly by the patient. Complaints such as headache and dizziness reflect the patient’s personal perception and cannot be independently verified. These findings are appropriately documented in the subjective section.
Correct Answer is B
Explanation
A. Request specific recommendations from the provider: This step occurs later during the Recommendation portion of ISBARR. At the beginning of the communication, the nurse must first clearly state why the call is urgent before asking for orders or guidance.
B. Describe the current client condition and critical changes requiring attention: After identification, the Situation is prioritized to immediately communicate what is happening now. This ensures the provider quickly understands the urgency related to deteriorating vital signs.
C. Read back the orders given by the provider for clarification: Read-back occurs at the end of the communication to confirm accuracy of orders. It is not appropriate until recommendations have been made and instructions received.
D. Provide detailed background information including medical history: Background information follows the situation and should be concise. Providing extensive history too early can delay recognition of a life-threatening change in the client’s condition.
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