During the initiation phase of the home visit, the home health nurse will
1. Contact the client and approach the visit with self-confidence.
2. Document care that is to be provided by the nurse and other team members.
3. Perform an inspection of the client's environment and functional status.
4. Review the chart or records left in the home to make sure permissions are signed and records are up-to-date.
ANS: 4
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The nurse is caring for a client who presents with achy jaw pain. Which assessment technique does the nurse use to determine whether the client has inflammation of the temporomandibular joint (TMJ)?
a. Checking for decayed, fractured, loose, or missing teeth b. Observing the jaw joint as the client chews a piece of food c. Palpating the joint during movement for tenderness or crepitus d. Observing for asymmetric joint protrusion when the client's mouth is closed
The nurse knows that when clients become severely mentally ill, they have trouble coping and keeping up with family roles and responsibilities
When family members assume these roles for the client, this is considered Stage 3 of family recovery and consists of: A) Acceptance and coping. B) Recognition and acceptance. C) Personal and political advocacy. D) Coping and competence.
How often should a nurse plan to observe a client in restraints?
A) At least every 5 minutes B) Continually C) At least every 15 minutes D) Every 2 hours
A patient with severe injuries is irritable, angry, and belittles the nurses. As a nurse changes a dressing, the patient screams, "Don't touch me! You are so stupid. You will make it worse!"
Which intervention uses a cognitive technique to help the patient? a. Wordlessly discontinue the dressing change, and then leave the room. b. Stop the dressing change, saying, "Perhaps you would like to change your own dressing." c. Continue the dressing change, saying, "Do you know this dressing change is needed so your wound will not get infected?" d. Continue the dressing change, saying, "Unfortunately, you have no choice in this because your doctor ordered this dressing change."