Physiological Adaptation Q 52

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The home health nurse visits a male client to provide wound care and finds the client lethargic and confused. His wife states he fell down the stairs two (2) hours ago. The nurse should

  

     A. Place a call to the client’s health care provider for instructions

     B. Send him to the emergency room for evaluation

     C. Reassure the client’s wife that the symptoms are transient

     D. Instruct the client’s wife to call the doctor if his symptoms become worse

    

    

Correct Answer: B. Send him to the emergency room for evaluation

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This client requires immediate evaluation. A delay in treatment could result in further deterioration and harm. Home care nurses must prioritize interventions based on assessment findings that are in the client’s best interest.

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Option A: Waiting to call for instructions may delay the diagnosis of the patient.

Option C: Reassuring the wife is incorrect since it is not a transient symptom.

Option D: The symptoms are indicative of an emergency situation so the patient must be brought to the emergency department immediately.

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