a client reports feeling isolated and lonely two weeks after the death of a spouse what is the most appropriate nursing intervention
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Nursing Elites

HESI LPN

Adult Health Exam 1

1. A client reports feeling isolated and lonely two weeks after the death of a spouse. What is the most appropriate nursing intervention?

Correct answer: D

Rationale: During the grieving process, individuals may benefit from various interventions to cope with their emotions and feelings of isolation. Encouraging the client to talk about the deceased spouse can provide an outlet for their emotions. Providing information on grief counseling can offer professional support tailored to their needs. Suggesting joining a support group can help the client connect with others who are going through a similar experience, fostering a sense of belonging and understanding. By selecting 'All of the above' as the correct answer, it acknowledges the importance of utilizing multiple strategies to support the client's emotional health and facilitate the grieving process effectively. The other options alone may not address all aspects of the client's needs during this difficult time.

2. A new mother is at the clinic with her 4-week-old for a well-baby check-up. The nurse should tell the mother to anticipate that the infant will demonstrate which milestone by 2 months of age?

Correct answer: B

Rationale: The correct answer is B because social smiling is a developmental milestone typically expected around 2 months of age. At this stage, infants start to engage more with their caregivers and show positive emotional responses. The other choices are incorrect. Choice A describes a motor skill that usually emerges later. Choice C involves more coordination and exploration, which is not typically seen by 2 months. Choice D relates to head control and arm strength, which also develop progressively but may not be fully achieved by 2 months.

3. A client undergoing chemotherapy reports a sudden onset of severe back pain. What should the nurse do first?

Correct answer: B

Rationale: The correct first action for the nurse is to assess the nature and intensity of the pain. This initial assessment is crucial in determining the underlying cause of the pain, whether it is related to the chemotherapy or another issue. Understanding the pain's characteristics will guide the nurse in implementing appropriate interventions and seeking timely medical assistance if needed. Administering pain medication without a thorough assessment may mask important symptoms and delay necessary treatment. Encouraging rest and hot pack application may be appropriate interventions but should come after assessing the pain. Notifying the physician immediately can be important but should follow the initial assessment to provide comprehensive information to the healthcare provider.

4. In a community health setting, which individual is at highest risk for contracting an HIV infection?

Correct answer: C

Rationale: The correct answer is C. Substance abuse, particularly using shared inhalation equipment like needles and pipes for drug inhalation, significantly increases the risk of contracting HIV. Choice A, the 17-year-old with multiple sexual partners, poses a risk of HIV transmission through sexual contact, but it is lower compared to the direct risk associated with sharing drug paraphernalia. Choice B, the 34-year-old homosexual in a monogamous relationship, is at lower risk since being in a monogamous relationship reduces exposure to HIV. Choice D, the 45-year-old who received blood transfusions, is also at lower risk as blood transfusions are now screened for HIV, decreasing the likelihood of transmission through this route.

5. A client with a history of hypertension is admitted to the hospital for a suspected myocardial infarction. Which of the following is the priority nursing action?

Correct answer: B

Rationale: The priority nursing action in this scenario is to perform an ECG. An ECG is crucial in confirming myocardial infarction promptly and guiding immediate treatment decisions. Administering oxygen as prescribed is important but not the priority over confirming the diagnosis. Obtaining a detailed health history is relevant but does not take precedence over immediate diagnostic confirmation. While monitoring vital signs regularly is essential, performing an ECG is the priority action in this scenario to guide timely management.

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