A home health nurse is planning care for a client who has right-sided weakness following a recent cerebrovascular accident. The client reports feeling unsteady when walking. Which of the following interventions should the nurse include?

Obtain a prescription to refer the client to physical therapy.

Instruct the client to wear sandals when ambulating.

Encourage the client to dim the lights in hallways.

Instruct the client to place throw rugs on bathroom floors.

Answer and Explanation

The Correct Answer is A

Rationale:
A. Obtain a prescription to refer the client to physical therapy: A referral to physical therapy is appropriate because therapists can design individualized exercises to improve balance, coordination, and strength. This intervention promotes safe mobility, enhances independence, and reduces fall risk for clients with post-stroke weakness.

B. Instruct the client to wear sandals when ambulating: Sandals do not provide adequate foot support or traction and increase the risk of tripping or falling. Clients with right-sided weakness should wear well-fitting, non-skid shoes to ensure safety and stability during ambulation.

C. Encourage the client to dim the lights in hallways: Poor lighting impairs visibility and increases the risk of falls, especially for clients with weakness or gait instability. Adequate illumination in hallways and pathways is essential for safety during ambulation.

D. Instruct the client to place throw rugs on bathroom floors: Throw rugs are a major fall hazard due to their tendency to slip or bunch up. The nurse should advise removing rugs or securing them with non-slip backing to create a safe, stable walking environment.

Nursing Test Bank

Test Bank #1: RN Pharmacology Exams Test Bank #2: RN Medical-Surgical Exams Test Bank #3: RN Fundamentals Exams Test Bank #4: RN Maternal-Newborn Exams Test Bank #5: RN Anatomy and Physiology Exams Test Bank #6: RN Obstetrics and Pediatrics Exams Test Bank #7: RN Fluid and Electrolytes Exams Test Bank #9: RN Adult Health Test Bank #10: RN Dosage Calculation Test Bank #11: RN Community Health Exams Test Bank #12: RN Psychology Exams Test Bank #13: RN Nursing Care Of Children Test Bank #14: RN Foundations of Nursing Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Exam #1: RN Comprehensive predictor 2023 proctored exam Exam #2: Ati rn vati comprehensive predictor proctored exam Exam #3: Ati Rn Comprehensive Predictor Proctored Exam 2023 Exam #4: Rn Comprehensive Predictor 2023 Proctored Exam - St. Joseph Exam #5: RN Comprehensive Predictor Proctored Exam (National U CA San Diego) Exam #6: Ati rn comprehensive predictor 2023 retake proctored exam Exam #7: RN Hesi Exit Proctored Exam Exam #8: Hesi RN Exit proctored exam Exam #9: Hesi rn exit proctored exam Exam #10: Hesi Rn compass exit B proctored exam

Free Nursing Study Resources

Correct Answer is ["A","B","D","E"]

Explanation

Rationale:
A. Obtain a culture specimen of the lochia from the client's perineal pad using a sterile swab: The client exhibits signs of postpartum infection, including foul-smelling lochia, fever, and elevated WBC count. Collecting a culture helps identify the causative organism and guide antibiotic therapy.

B. Instruct the client to wash her hands before and after changing her perineal pad: Hand hygiene reduces the risk of introducing additional pathogens to the uterine or perineal area, supporting infection control and client safety.

C. Initiate contact precautions: Contact precautions are typically used for highly contagious or multidrug-resistant infections. Standard precautions, including hand hygiene, are sufficient for most postpartum infections like endometritis.

D. Encourage the client to maintain a semi-Fowler's position to enhance uterine drainage: Semi-Fowler’s positioning promotes drainage of lochia, reduces uterine stasis, and helps prevent further infection or discomfort.

E. Monitor the height and tone of the client's fundus: Regular assessment of fundal height and tone is essential postpartum to detect uterine atony, retained tissue, or infection. Monitoring ensures early intervention if complications develop.

F. Request a prescription for terbutaline from the provider: Terbutaline is a tocolytic used to suppress preterm labor. There is no indication for its use in this postpartum client with uterine infection.

G. Inform the client she will need to formula feed her newborn until she has received antibiotics for 24 hr: Most antibiotics, including clindamycin, are compatible with breastfeeding. The client does not need to discontinue breastfeeding unless specifically contraindicated.

A. A client who describes feeling disconnected from those around him following the hurricane. B. A client who describes having persistent feelings of anger about the hurricane. C. A client who has frequent nightmares about the hurricane. D. A client who moved to an apartment located on higher ground than her previous home. E. A client who expresses a realization that life will not return to the way it was before the hurricane.

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

Explanation

Rationale:
A. A client who describes feeling disconnected from those around him following the hurricane: Emotional detachment or a sense of estrangement from others is a hallmark symptom of posttraumatic stress disorder (PTSD).

B. A client who describes having persistent feelings of anger about the hurricane: Ongoing irritability, anger, or emotional outbursts several months after a traumatic event may indicate unresolved trauma or hyperarousal, which are common features of PTSD.

C. A client who has frequent nightmares about the hurricane: Recurrent distressing dreams or flashbacks related to the traumatic event are hallmark re-experiencing symptoms of PTSD. Such nightmares suggest the trauma continues to affect the client’s sleep and mental health, justifying referral for further assessment.

D. A client who moved to an apartment located on higher ground than her previous home: Moving to a new location demonstrates adaptive coping and an effort to regain a sense of safety. This behavior does not indicate the presence of PTSD symptoms.

E. A client who expresses a realization that life will not return to the way it was before the hurricane: Acceptance and acknowledgment of change represent a healthy adjustment process. While grief or sadness may accompany this awareness, it reflects adaptation rather than pathological stress or trauma.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

A home health nurse is planning care for a client who has right-sided weakness following a recent cerebrovascular accident. The client reports feeling unsteady when walking. Which of the following interventions should the nurse include?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse reviews the provider prescriptions and reassesses the client. Exhibits The nurse is continuing to care for the client. Which of the following actions should the nurse take? Select all that apply.

Correct Answer is ["A","B","D","E"]

Explanation

A nurse is counseling a group of clients from a town that was affected by a hurricane 6 months ago. For which of the following clients should the nurse initiate a referral to assess for the presence of posttraumatic stress disorder? (Select all that apply.)

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

Explanation

A nurse is preparing to administer labetalol 40 mg IV to a client. Available is labetalol 5 mg/mL. How many mL should the nurse administer? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.)

A nurse is providing nutrition teaching for a client who has hypertension. Which of the following foods should the nurse suggest the client include in their diet?

A nurse is caring for a toddler in the outpatient setting. Exhibits Complete the following sentence by using the lists of options. The nurse recognizes the toddler has likely developed dropdown due to dropdown.

A nurse is caring for a client who has lung cancer and has a sealed radiation implant. Which of the following actions should the nurse take? (Select all that apply.)

A nurse is caring for a client who is to undergo a bilateral prophylactic mastectomy. The client states that her family opposes her decision. Which of the following responses should the nurse make?

A nurse is caring for a client who is postpartum and requests information about contraception. Which of the following instructions should the nurse include?

A nurse is planning care for a client who has reduced visual sensory perception. Which of the following interventions should the nurse include in the plan of care?