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.
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
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B","D","E","F"]
Explanation
Rationale:
A. Fundal height: The fundus has descended to 4 cm below the umbilicus and remains firm, indicating effective involution of the uterus and improvement from the previously boggy, tender fundus.
B. Heart rate: The client’s heart rate has decreased from 110/min on postpartum day 3 to 88/min on day 5, reflecting stabilization and decreased physiologic stress.
C. Hgb: Hemoglobin decreased slightly from 11.1 g/dL to 10 g/dL. While this is a minor drop, it does not indicate improvement and may reflect ongoing blood loss or hemodilution postpartum.
D. Temperature: The client’s temperature has normalized to 37.2° C (99° F) from febrile readings of 38.6° C (101.5° F), indicating resolution of the infection or inflammatory process.
E. WBC count: The WBC count decreased from 33,000/mm³ to 10,000/mm³, demonstrating resolution of the previous leukocytosis associated with infection or postpartum inflammation.
F. Lochia: Lochia has decreased in amount, is brownish-red without odor, indicating normal postpartum progression and resolution of the previously foul-smelling discharge, signifying improvement.
Correct Answer is A
Explanation
Rationale:
A. "I will ask your provider to discuss options for discontinuing treatment with you.": This response supports the client’s autonomy and right to refuse treatment while ensuring that the provider is informed to discuss the medical and ethical aspects of stopping therapy. It reflects respect for the client’s wishes and promotes shared decision-making.
B. "You cannot legally discontinue treatment unless you have a living will.": A living will is not required for a client to refuse or discontinue treatment. Competent clients have the legal and ethical right to make decisions about their own care, including the choice to stop therapy, regardless of advance directives.
C. "You must continue with these treatments because they are lifesaving.": This statement disregards the client’s autonomy and imposes the nurse’s opinion on the client’s decision. Even if the treatment is potentially lifesaving, the client has the right to decline it based on their personal values and quality-of-life considerations.
D. "I know your provider thinks these treatments are necessary for you.": This response shifts focus away from the client’s preferences and reinforces the provider’s opinion instead. It fails to acknowledge the client’s emotional and ethical right to choose.
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
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.