A home care nurse is inspecting a patient’s house for safety issues. Which findings will cause the nurse to address the safety problems? (Select all that apply)
Bathtub with grab bars
Stairway faintly lit
Low pile carpeting in the living room.
Scatter rugs in the kitchen
Absence of smoke alarms
The Correct Answer is B
Choice A reason: Bathtub grab bars enhance safety by preventing falls during bathing, a common risk area for injuries. This is a positive finding, reducing the likelihood of accidents, and does not require intervention. The nurse would not address this as a safety problem, making it incorrect.
Choice B reason: A faintly lit stairway increases fall risk, especially for older adults or those with visual impairments. Poor lighting obscures steps, leading to missteps or tripping. The nurse must address this by recommending brighter lighting or handrails to ensure safe navigation, making this a correct safety concern.
Choice C reason: Low pile carpeting is safe, as it reduces tripping hazards compared to high pile or loose rugs. It provides stable footing without obstructing mobility. This finding does not pose a safety risk, so the nurse would not address it, making it an incorrect choice.
Choice D reason: Scatter rugs in the kitchen are a tripping hazard, particularly in high-traffic areas. They can slide or bunch, increasing fall risk, especially for elderly patients. The nurse must address this by recommending removal or securing rugs, making this a correct safety concern to mitigate accidents.
Choice E reason: Absence of smoke alarms is a critical safety issue, as it leaves the home vulnerable to undetected fires, endangering the patient. The nurse must address this by recommending installation of smoke detectors, ensuring early warning for emergencies, making this a correct safety concern.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A reason: Respirations of 22 and heart rate of 66 suggest arousal or light sleep, not deep NREM sleep, which features slower, regular breathing (12-16 breaths/min) and lower heart rate. This indicates discomfort or instability, not comfortable sleep. Assuming this reflects NREM sleep risks overlooking signs of inadequate rest or stress in ICU patients.
Choice B reason: Mumbling to self indicates partial arousal or REM sleep, not NREM sleep, which is characterized by minimal movement and stable vitals. This suggests discomfort or neurological disturbance. Assuming NREM sleep misidentifies the sleep stage, potentially missing interventions to promote deeper, restorative sleep critical for ICU patient recovery.
Choice C reason: Tossing in bed with respirations of 18 and heart rate of 80 indicates restlessness or light sleep, not deep NREM sleep, which involves calm, slow vitals. This suggests discomfort or pain. Assuming NREM sleep risks neglecting interventions like pain management, critical for ensuring restorative sleep in ICU settings.
Choice D reason: Eyes closed, lying quietly, with respirations of 12 and heart rate of 60 indicate deep NREM sleep, characterized by slow, regular breathing and low heart rate, reflecting parasympathetic dominance. This confirms comfortable, restorative sleep, critical for healing in ICU patients, guiding nurses to maintain conditions supporting this optimal sleep state.
Correct Answer is B
Explanation
Choice A reason: Low blood pressure is not typically associated with prolonged stress. Chronic stress elevates cortisol, which can increase blood pressure via sympathetic activation. Hypotension may occur in acute stress response (e.g., shock), but prolonged stress more commonly causes hypertension, making this an incorrect condition to monitor.
Choice B reason: Prolonged stress suppresses immune function by elevating cortisol, reducing lymphocyte activity and increasing infection risk. Conditions like respiratory or urinary tract infections become more likely. Monitoring for infections is essential, as stress weakens the body’s ability to fight pathogens, making this a correct condition to assess.
Choice C reason: Alopecia, or hair loss, can result from prolonged stress due to elevated cortisol disrupting hair follicle cycles, leading to telogen effluvium. Stress-induced autoimmune conditions like alopecia areata may also occur. Monitoring for hair loss is appropriate, as it reflects stress’s physiological impact, making this a correct choice.
Choice D reason: Prolonged stress increases diabetes risk by raising cortisol and catecholamines, which elevate blood glucose and impair insulin sensitivity. This can exacerbate or precipitate type 2 diabetes. Monitoring glucose levels is critical, as stress contributes to metabolic dysregulation, making this a correct condition to assess.
Choice E reason: Chronic stress is linked to cancer through immune suppression and inflammation, which may promote tumor growth. Elevated cortisol and stress hormones can impair DNA repair mechanisms. Monitoring for cancer risk, especially in high-stress patients, is warranted, as stress is a known risk factor, making this a correct choice.
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