A home health nurse is providing care to an older adult client during the winter. During an in-home visit, the nurse notes that the thermostat is set to 12.8° C (55° F). The client tells the nurse, "I keep the heat set low because I can't afford to pay the bill." Which of the following actions should the nurse take?
Recommend staying at a local shelter until the client can afford the bill.
Contact the local Department of Health and Human Services for the client.
Contact the client's family members to tell them the client's financial status.
Provide the client with written information about the dangers of hypothermia.
The Correct Answer is B
The nurse should contact the local Department of Health and Human Services for the client, as this agency may be able to provide assistance with heating costs or other resources for low-income individuals.
Older adults are at increased risk of hypothermia, which is a potentially life-threatening condition that occurs when body temperature drops below 35° C (95° F). Hypothermia can be caused by exposure to cold temperatures, inadequate clothing, poor nutrition, chronic illness, or medication use. Therefore, it is important for the nurse to intervene and help the client maintain a safe and comfortable home environment.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
The priority intervention for the nurse is to determine whether the client has an allergy to local anesthetics, as this could cause a serious adverse reaction during the procedure.
Thoracentesis is a minimally invasive procedure that involves inserting a needle into the pleural space to drain excess fluid or air from around the lungs. The procedure requires local anesthesia to numb the area where the needle is inserted. Therefore, it is essential to assess for any allergy to local anesthetics before proceeding with the procedure.
Correct Answer is B
Explanation
To assess a client for a positive Chvostek’s sign, the nurse should tap gently on the cheek, specifically two centimeters in front of the ear, over the facial nerve (also known as CN VII). This test is used to check for hypocalcemia, a condition that can lead to tetany, which is the involuntary contraction of muscles. A twitch of the facial muscles in response to this tapping indicates a positive Chvostek’s sign. This is particularly relevant following a thyroidectomy, as the procedure can indirectly affect the parathyroid glands, potentially leading to hypocalcemia
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