A home health nurse is conducting a safety assessment for a client with decreased vision due to glaucoma. Which of the following interventions should the nurse prioritize to ensure a safe home environment for the client? Select all that apply

Place throw rugs and carpets throughout the home to add comfort and warmth.

Ensure that all electrical cords and wires are secured against walls and out of walkways.

Install bright, overhead lighting in every room and hallway to improve visibility.

Encourage the client to use a walking stick or guide dog when moving around the home.

Label kitchen cabinets and drawers with large-print, high-contrast labels.

Answer and Explanation

Correct Answer : B,C,D,E

A. Place throw rugs and carpets throughout the home to add comfort and warmth: Throw rugs and carpets can increase the risk of falls, especially for clients with vision impairments. They should be avoided.

B. Ensure that all electrical cords and wires are secured against walls and out of walkways: Preventing tripping hazards is critical for a client with vision impairment.

C. Install bright, overhead lighting in every room and hallway to improve visibility: Adequate lighting is essential for clients with glaucoma to help them navigate safely.

D. Encourage the client to use a walking stick or guide dog when moving around the home: This enhances mobility and safety for clients with decreased vision by providing support and guidance.

E. Label kitchen cabinets and drawers with large-print, high-contrast labels: This helps the client identify items more easily and reduces the risk of injury or confusion.

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Correct Answer is A

Explanation

A. Level of sedation. Assessing sedation is the priority because excessive sedation could indicate opioid toxicity, which may precede respiratory depression.

B. Pain level. While assessing pain is essential, it is not the priority when evaluating the safety of opioid administration.

C. Pulse oximetry. Monitoring oxygenation is critical but follows the assessment of sedation, which directly relates to the risk of respiratory depression.

D. Blood pressure. Blood pressure monitoring is important but not as immediate a concern as sedation and respiratory function.

A. Observe the patient's facial expressions and body language for signs of discomfort. B. Measure the patient's vital signs and note any changes. C. Review the patient's medical history for past pain management interventions and their outcomes. D. Ask the patient to describe the pain using a pain scale and provide details about its location, duration, and intensity.

Correct Answer is D

Explanation

A. Observe the patient's facial expressions and body language for signs of discomfort: While observation is important, it doesn't provide a complete picture of the client's pain experience and may not capture all aspects, such as intensity or location.

B. Measure the patient's vital signs and note any changes: Vital signs are important but can be nonspecific indicators of pain and are not as reliable for assessing pain intensity or quality.

C. Review the patient's medical history for past pain management interventions and their outcomes: While this is useful, it does not directly address the client's current pain experience.

D. Ask the patient to describe the pain using a pain scale and provide details about its location, duration, and intensity. A comprehensive pain assessment requires the client's self-report to fully understand the pain's characteristics. A pain scale (e.g., 0-10) helps quantify the intensity, and asking about its location, duration, and type allows for a thorough understanding of the pain's impact.

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A home health nurse is conducting a safety assessment for a client with decreased vision due to glaucoma. Which of the following interventions should the nurse prioritize to ensure a safe home environment for the client? Select all that apply

Nursing Test Bank

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Correct Answer is D

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