A nurse is providing discharge teaching about safety considerations to an older adult client who lives at home. The client has heart failure and a new prescription for hydrochlorothiazide. Which of the following statements by the client indicates an understanding of the teaching?
"I will weigh myself once weekly."
"I will take my new medication in the evening."
"I will take a hot bath before going to bed."
"I will leave a light on in my bathroom at night."
The Correct Answer is D
A. "I will weigh myself once weekly." Clients with heart failure should weigh themselves daily to monitor for fluid retention. A sudden weight gain (e.g., 2-3 lbs in 24 hours or 5 lbs in a week) may indicate worsening heart failure and should be reported to the provider.
B. "I will take my new medication in the evening." Hydrochlorothiazide is a diuretic that increases urine output. Taking it in the evening can lead to nocturia and sleep disturbances. Instead, it should be taken in the morning to minimize nighttime urination.
C. "I will take a hot bath before going to bed." Hot baths can cause vasodilation, leading to a drop in blood pressure (orthostatic hypotension), which increases the risk of dizziness and falls, especially in older adults taking diuretics. A warm (not hot) bath is safer.
D. "I will leave a light on in my bathroom at night." Older adults, especially those taking diuretics like hydrochlorothiazide, are at increased risk for nocturia and falls due to frequent trips to the bathroom. Keeping a light on in the bathroom at night enhances visibility and reduces the risk of falls, which is a major concern in this population.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. "I will move your joints to the point of mild pain." - This statement is incorrect. Passive ROM exercises should not be performed to the point of causing pain. Pain during passive ROM exercises can indicate that the movement is too forceful or beyond the client's range of motion, which can lead to injury or discomfort.
B. "I will repeat these movements 3 to 5 times." - This statement is generally correct. Passive ROM exercises are typically repeated several times during each session to help maintain joint mobility and prevent contractures. The specific number of repetitions can vary based on the client's needs and tolerance.
C. "I will move your joints quickly." - This statement is incorrect. Passive ROM exercises should be performed slowly and gently to avoid causing discomfort or injury to the client. Slow movements allow for better control and precision, ensuring that the joints are moved through their full range of motion without undue force.
D. "These movements will be performed once per day." - This statement is incorrect. Passive ROM exercises are usually performed multiple times throughout the day, especially for clients with decreased mobility. Regular and frequent sessions help prevent stiffness, maintain flexibility, and promote circulation in the joints.
Correct Answer is B
Explanation
A. Swing-through gait:
The swing-through gait is a more advanced gait pattern used by clients with significant lower extremity weakness or paralysis. It involves swinging both crutches forward simultaneously, followed by swinging both legs forward past the crutches. This gait is not appropriate for a client who can only bear weight on one leg.
B. Three-point gait:
The three-point gait is typically used when one lower extremity is completely non-weight-bearing. It involves advancing both crutches and then swinging the affected leg through to meet the crutches. Since the client in this scenario can bear weight on one leg, the three-point gait is the most appropriate choice.
C. Four-point alternating gait
Four-point alternating gait
The four-point alternating gait involves a sequence of movements where each crutch and each leg move alternately. The sequence is as follows:
- Move the right crutch forward(injured side).
- Move the left foot forward(non-injured side).
- Move the left crutch forward(non-injured side).
- Move the right foot forward(injured side). This gait offers stability and control but requires more effort and coordination.
D. Two-point alternating gait:
The two-point alternating gait involves moving one crutch and the opposite lower extremity forward simultaneously, followed by moving the other crutch and the opposite lower extremity forward. This gait pattern is typically used by clients who have good balance and strength in both lower extremities. It may not provide enough stability and support for a client who can only bear weight on one leg.
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