A home health nurse is conducting a home safety assessment for an older adult client. Which of the following findings should the nurse identify as a safety risk for the client? (Select all that apply.)

Water heater temperature 54.4°C (130° F)

Throw rugs

Electric cords behind the furniture

Raised toilet seats

Bathtub with rails

Answer and Explanation

Correct Answer : A,B

A. A water heater temperature of 54.4°C (130°F) poses a burn risk, especially for older adults who may have decreased sensitivity to temperature changes. The recommended safe temperature for water heaters is usually around 49°C (120°F) to prevent scalding.

B. Throw rugs are a significant safety hazard as they can easily cause slips and falls, particularly for older adults who may have balance issues or mobility challenges.

C. Electric cords behind furniture do not pose an immediate tripping hazard, making this a lower safety risk compared to other options. However, cords should be checked for damage and overheating risks.
D. Raised toilet seats are typically considered a safety measure for older adults, as they can aid in sitting down and standing up, making it easier for individuals with mobility issues.

E. Bathtubs with rails are also a safety feature, providing support and stability for older adults when entering and exiting the tub, reducing the risk of falls.

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Correct Answer is D

Explanation

a. Hypertension and crackles:

While hypertension can be associated with various conditions, such as cardiovascular diseases or stress, it is not directly related to the cessation of TPN infusion.

Crackles in the lungs are often indicative of fluid accumulation or inflammation, commonly seen in conditions like pneumonia or heart failure. They are not typically associated with the interruption of TPN infusion.

b. Fever and chills:

Fever and chills can be symptoms of infection or inflammatory processes in the body. However, they are not specifically related to the interruption of TPN infusion.

In the context of TPN cessation, the focus would be on metabolic changes rather than infectious processes.

c. Excessive thirst and urination:

Excessive thirst and urination are classic symptoms of hyperglycemia, which can occur when TPN, particularly if it contains a high glucose concentration, is abruptly interrupted.

When TPN infusion stops, there is no longer a continuous supply of glucose to the body, leading to increased blood glucose levels and subsequent polyuria (excessive urination) and polydipsia (excessive thirst) as the body tries to eliminate excess glucose.

d. Shakiness and diaphoresis:

Shakiness and diaphoresis (excessive sweating) are classic symptoms of hypoglycemia, which can occur if TPN, particularly if it contains a high concentration of insulin, is abruptly interrupted.

TPN solutions often contain glucose and insulin to maintain proper blood glucose levels. If the infusion is stopped suddenly, there may be a rapid decline in blood glucose levels, leading to hypoglycemia, which manifests as shakiness, diaphoresis, confusion, and other neuroglycopenic symptoms.

A. Increased fiber in the diet B. Ignoring the urge to defecate C. Inadequate fluid intake D. Increased activity E. Excessive laxative use

Correct Answer is ["B","C","E"]

Explanation

A. Increased fiber in the diet is not a cause of constipation, but rather a preventive measure that can help promote regular bowel movements by adding bulk and softness to the stool.
B. Ignoring the urge to defecate is a cause of constipation, as it can lead to hardening and accumulation of fecal matter in the colon, resulting in difficulty and pain during defecation.
C. Inadequate fluid intake is a cause of constipation, as it can contribute to dehydration and reduced stool moisture, making it harder and drier to pass.
D. Increased activity is not a cause of constipation, but rather a beneficial factor that can stimulate intestinal motility and facilitate bowel elimination.
E. Excessive laxative use is a cause of constipation, as it can interfere with the normal functioning of the colon and cause dependence, leading to decreased bowel tone and reduced peristalsis.

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A home health nurse is conducting a home safety assessment for an older adult client. Which of the following findings should the nurse identify as a safety risk for the client? (Select all that apply.)

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Naxlex Comprehensive Predictor Exams

A nurse is assessing a client and discovers the infusion pump with the client's total parenteral nutrition (TPN) solution is not infusing. The nurse should monitor the client for which of the following conditions?

Correct Answer is D

Explanation

A nurse is teaching a client who has constipation. Which of the following should the nurse discuss as causes of constipation? (Select all that apply.)

Correct Answer is ["B","C","E"]

Explanation

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