A home health nurse is caring for an older adult client who is immobile. What question should the nurse ask to collect information about the client's safety?

"Who helps cook and clean for you? You don't do it all yourself, do you?"

"How do you get your daily exercise with your immobility limitations?"

"How do you usually get your medications each day?"

"Tell me about a typical day. Do you feel secure in your environment?"

Answer and Explanation

The Correct Answer is D

A. "Who helps cook and clean for you? You don't do it all yourself, do you?": This question assesses support for activities of daily living but does not directly address the client’s safety in their environment.

B. "How do you get your daily exercise with your immobility limitations?": This question explores physical activity and mobility, which can impact health, but it does not fully capture environmental safety or risk for injury at home.

C. "How do you usually get your medications each day?": Understanding medication management is important for adherence and safety, but it focuses on a single aspect of safety rather than the broader home environment.

D. "Tell me about a typical day. Do you feel secure in your environment?": This question directly addresses the client’s perception of safety and allows the nurse to identify potential hazards, falls risks, or other environmental concerns. It provides comprehensive information about the client’s safety and daily functioning.

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Free Nursing Study Resources

Correct Answer is C

Explanation

A. A client with a burn on their forearm sustained from boiling water: While burns require assessment and care, a forearm burn without signs of systemic compromise is not immediately life-threatening and can wait after more urgent cases.

B. A client with a right ankle fracture unable to place any weight on it: An isolated fracture causes pain and limited mobility but is not life-threatening, making it lower priority in triage compared to clients with potential systemic compromise.

C. A client with severe abdominal pain who is pale and diaphoretic: Pallor and diaphoresis indicate possible shock or serious internal pathology. This client is at highest risk for rapid deterioration and requires immediate assessment and intervention.

D. A client with a head laceration being controlled with pressure: If bleeding is controlled and the client is stable, this is urgent but not immediately life-threatening, so the client can be assessed after those showing signs of shock or systemic compromise.

A. Determine the preferred communication methods with the client. B. Put a table between the nurse and the client to take notes. C. Ask the client if they can bring a family member to the next visit D. Sit in a chair to the side of the client.

Correct Answer is A

Explanation

A. Determine the preferred communication methods with the client: Identifying the client’s preferred methods, such as speaking clearly, using written notes, or adjusting hearing aids, ensures effective communication. This approach promotes accurate information gathering and client engagement during the interview.

B. Put a table between the nurse and the client to take notes: Placing a physical barrier can impede visual and auditory communication cues. Effective communication requires clear sightlines and direct interaction rather than obstacles that may hinder understanding.

C. Ask the client if they can bring a family member to the next visit: While family support can help with communication, the immediate priority is to establish effective communication directly with the client during the current interview, respecting their independence and privacy.

D. Sit in a chair to the side of the client: Sitting to the side may make it difficult for the client to see facial expressions and lip movements, which are important for clients with hearing impairments. Facing the client directly is more effective for clear communication.

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A home health nurse is caring for an older adult client who is immobile. What question should the nurse ask to collect information about the client's safety?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Explanation

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Correct Answer is A

Explanation

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