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 A
Explanation
A. Prepare the client for surgery: In emergency situations, if immediate intervention is required to save the client’s life or prevent significant harm, the principle of implied consent may apply. This means that if the client is unconscious and immediate treatment is necessary, healthcare providers may proceed with treatment under the assumption that the client would consent if able. However, this should be done in accordance with facility policies and legal guidelines.
B. Contact the facility's ethics committee for guidance: Contacting the ethics committee can be helpful for guidance on how to handle consent issues in complex situations, but it might not provide a timely solution for immediate emergency situations.
C. Keep the client stable until a family member arrives to give consent: While stabilizing the client's condition is important, waiting for a family member to arrive to give consent may not be feasible in emergency situations where immediate treatment is necessary. The nurse should seek guidance from appropriate channels to determine the best course of action.
D. Obtain consent from the surgeon: Surgeons do not have the authority to provide consent for treatment on behalf of a client who is unconscious. Consent must come from a legally authorized decision-maker, such as the client themselves if they have previously provided informed consent, or a designated healthcare proxy.
Correct Answer is A
Explanation
A. Assault.
Assault is the threat or apprehension of harmful or offensive contact. In this scenario, the nurse is making a threat to administer medication by injection if the client doesn't comply with swallowing pills. Even though the nurse hasn't physically carried out the action yet, the threat itself constitutes assault. The client feels threatened by the nurse's statement, creating apprehension of harm or offensive contact.
B. Defamation: Defamation involves making false statements that harm a person's reputation. There is no indication of defamation in this scenario.
C. Battery: Battery involves the intentional and unauthorized touching of another person. While administering medication by injection without consent could be considered battery, the nurse has only made a threat at this point, not carried out the action.
D. Invasion of privacy: Invasion of privacy involves intruding into someone's private affairs without permission. There is no indication of invasion of privacy in this scenario.
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