A nurse is conducting an initial home health assessment for an older adult who has a new diagnosis of moderate Alzheimer's disorder and lives with their caregiver. For which of the following findings should the nurse obtain a referral to a physical therapist?

The client has gained 4.5 kg (10 lb) over 8 weeks.

The caregiver reports that recently the client is incontinent of urine during the day.

The client is unable to climb the stairs to their bedroom.

The caregiver reports the client needs assistance with activities of daily living such as bathing

Answer and Explanation

The Correct Answer is C

A. The client has gained 4.5 kg (10 lb) over 8 weeks: Weight gain may indicate changes in diet, activity, or medication, but it does not directly suggest a need for physical therapy. A nutritionist or primary care provider might be more appropriate for follow-up.

B. The caregiver reports that recently the client is incontinent of urine during the day:
Urinary incontinence in clients with Alzheimer's is typically addressed by primary care or urology. It may be related to cognitive decline rather than physical impairment, so physical therapy is not the priority referral.

C. The client is unable to climb the stairs to their bedroom: This mobility limitation increases the risk for falls and functional decline. A physical therapist can assess strength, balance, and coordination, and develop a mobility plan or recommend assistive devices or home modifications.

D. The caregiver reports the client needs assistance with activities of daily living such as bathing: This indicates a need for occupational therapy to enhance independence in daily tasks. While physical therapy may support mobility, ADL support is better addressed by an occupational therapist.

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Correct Answer is D

Explanation

A. Instruct the client to change the end caps of the CVAD daily: Changing the end caps daily is not recommended because frequent manipulation can increase the risk of contamination. End caps should be changed per agency protocol or when visibly soiled or compromised.

B. Use clean technique when administering medication: Medication administration through a CVAD requires sterile technique—not just clean technique—to prevent the introduction of microorganisms into the bloodstream, which can lead to sepsis.

C. Clean blood spills on hard surfaces with isopropyl alcohol: While isopropyl alcohol is useful for small disinfectant tasks, blood spills should be cleaned with a disinfectant effective against bloodborne pathogens, such as a bleach-based solution, to ensure complete decontamination.

D. Use disposable equipment whenever possible: Using disposable equipment minimizes cross-contamination and is a key strategy in preventing healthcare-associated infections. This is particularly important in home care settings where sterilization capabilities are limited.

A. Cross legs at the ankles. B. Use an elevated toilet seat. C. Take baths instead of showers. D. Use a walker on the stairs.

Correct Answer is B

Explanation

A. Cross legs at the ankles: Crossing legs, even at the ankles, can increase the risk of hip dislocation following total hip arthroplasty by placing stress on the joint and is generally discouraged during recovery.

B. Use an elevated toilet seat: An elevated toilet seat helps maintain hip precautions by preventing excessive hip flexion, reducing dislocation risk, and promoting safety and comfort during toileting.

C. Take baths instead of showers: Baths require more hip flexion and increased risk of falling, so showers are preferred postoperatively to minimize hip strain and improve safety.

D. Use a walker on the stairs: Using a walker on stairs is unsafe due to limited maneuverability; crutches or a cane are usually recommended for stair navigation during hip recovery.

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A nurse is conducting an initial home health assessment for an older adult who has a new diagnosis of moderate Alzheimer's disorder and lives with their caregiver. For which of the following findings should the nurse obtain a referral to a physical therapist?

Nursing Test Bank

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