A nurse is interviewing a client at a clinic near a shelter for the homeless. Understanding the increased risk a poor physical environment creates for this client, on what should the nurse focus during the intake phase of the interview?
1. Lack of social support
2. Recent history of chills and body aches
3. Improper nutrition
4. Few personal resources
Correct Answer: 2
Rationale 1: Lack of social support contributes to health problems in general.
Rationale 2: A poor physical environment results in increased susceptibility to infections. The client's recent history of chills and body aches should alert the nurse that this client may have an infection.
Rationale 3: Improper nutrition contributes to health problems in general.
Rationale 4: Few personal resources contributes to health problems in general.
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A rape victim tells the emergency room nurse, "I feel so dirty. Help me take a shower before the doctor examines me.". The nurse should:
a. arrange for the patient to shower. b. explain that bathing would destroy evidence. c. give the patient a basin of water and towels. d. explain that bathing facilities are not available in the emergency department.
The nurse learns that a client of the Jewish faith does not eat certain types of foods and fasts on religious holidays. Which intervention would help support the client's cultural practice?
1. Research the client's practices. 2. Obtain a consult with the dietician. 3. Document the client's preferences on the assessment form. 4. Communicate the client's practices to the healthcare team.
Which condition alerts you to assess a patient for worsening heart failure?
a. Blood pressure of 106/40 mm Hg b. Pounding headache c. Foul urine odor d. Ankle swelling
The preoperative client expresses anxiety to the nurse about the upcoming surgery. Which of the following statements by the nurse is most likely to stimulate further discussion between the client and the nurse?
1. "If it's any help, everyone is nervous before surgery." 2. "I will be happy to explain the entire surgical procedure to you." 3. "Can you share with me what you've been told about your surgery?" 4. "Let me tell you about the care you'll receive after surgery and the amount of pain you can anticipate."