A home health nurse is reinforcing teaching about home safety with an older adult client who lives alone. Which of the following client statements indicates an understanding of the teaching?

"I will make sure that electrical wires are run under carpeting."

"I will have the heating system inspected once every 3 years."

"I will have my hearing tested every 2 years."

"I will make sure that my hot water faucets are color-coded."

Answer and Explanation

The Correct Answer is D

A. "I will make sure that electrical wires are run under carpeting.": This is not a safe practice. Running electrical wires under carpeting can lead to the wires overheating or becoming damaged, which is a fire hazard.

B. "I will have the heating system inspected once every 3 years.": The heating system should be inspected more frequently than every three years, ideally annually, to ensure safety and proper functioning.

C. "I will have my hearing tested every 2 years.": While hearing should be monitored regularly, this is not a specific home safety measure. A hearing impairment can increase the risk of falls or accidents.

D. "I will make sure that my hot water faucets are color-coded.": This is an important safety measure, particularly for older adults, as it helps prevent burns. Color-coded faucets can help prevent the risk of hot water burns by easily identifying hot and cold water.

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Correct Answer is A

Explanation

A. Neck is in a flexed position is correct. Torticollis (or wry neck) is a condition where the head is tilted to one side due to abnormal positioning of the neck muscles. The infant may exhibit a flexed or tilted neck, and there may be muscle tightness on one side of the neck.

B. Asymmetry of gluteal folds is incorrect. This finding is associated with hip dysplasia, not torticollis. Asymmetry of the folds could indicate a dislocated hip or other musculoskeletal issues.

C. Feet turn inward is incorrect. This finding suggests clubfoot rather than torticollis, a condition where the feet are turned inward and may require correctional intervention.

D. Frenulum connected to the tip of the tongue is incorrect. This describes a condition known as tongue-tie (ankyloglossia., which affects the tongue's movement and is unrelated to torticollis.

A. Pale-colored toes B. Decreased skin turgor C. Pain relieved by analgesia D. Diminished capillary refill E. Sensation of tingling

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

Explanation

A. Pale-colored toes are a sign of compromised circulation, which is a key manifestation of compartment syndrome. Decreased blood flow to the affected limb can cause pallor, which requires immediate intervention to prevent permanent damage.

B. Decreased skin turgor is incorrect. Skin turgor is an indicator of hydration status and is not directly related to compartment syndrome.

C. Pain relieved by analgesia is incorrect. One of the hallmark signs of compartment syndrome is severe pain that is not relieved by analgesia and worsens with passive movement.

D. Diminished capillary refill is correct. Delayed capillary refill (longer than 2 seconds) suggests poor perfusion, which can indicate increased pressure within the compartment.

E. Sensation of tingling is correct. Paresthesia (tingling or numbness) is an early sign of nerve compression due to swelling within the compartment. If untreated, this can progress to permanent nerve and muscle damage.

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A home health nurse is reinforcing teaching about home safety with an older adult client who lives alone. Which of the following client statements indicates an understanding of the teaching?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is collecting data from a 10-month-old infant during a well-child visit. Which of the following findings should the nurse identify as a manifestation of torticollis?

Correct Answer is A

Explanation

A nurse is monitoring a client's lower extremity following the placement of a cast earlier in the day. Which of the following findings should the nurse identify as manifestations of compartment syndrome? (Select all that apply.)

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

Explanation

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