A nurse is reinforcing teaching about home safety measures with a client who is visually impaired. Which of the following instructions should the nurse include?
Mark the edges of steps.
Use low-wattage light bulbs.
Place throw rugs over electrical cords.
Leave doors slightly ajar.
The Correct Answer is A
A. Mark the edges of steps: Marking the edges of steps with high-contrast tape or paint helps increase visibility and prevent falls for individuals with visual impairments.
B. Use low-wattage light bulbs: Using low-wattage light bulbs might reduce the brightness needed for safety. Higher-wattage bulbs or bright, energy-efficient lighting is usually recommended to improve visibility.
C. Place throw rugs over electrical cords: Placing throw rugs over electrical cords can create tripping hazards and is not a safe practice for individuals with visual impairments.
D. Leave doors slightly ajar: Leaving doors ajar can create obstacles and increase the risk of injury for someone with visual impairment, as they may not be able to detect the open door.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is {"A":{"answers":"A,B"},"B":{"answers":"A,B"},"C":{"answers":"B"},"D":{"answers":"A"},"E":{"answers":"A,B"}}
Explanation
Heart rate
• Hypovolemic Shock
o The elevated heart rate of 104/min is consistent with hypovolemic shock, where the body compensates for reduced blood volume by increasing heart rate to maintain cardiac output and perfusion.
• Pulmonary Embolism
o An increased heart rate can also occur with pulmonary embolism as the body responds to decreased oxygenation and impaired cardiac function.
Respiratory effort
• Hypovolemic Shock
o Increased respiratory rate of 24/min may be a compensatory mechanism in hypovolemic shock to enhance oxygen delivery to tissues despite reduced blood volume.
• Pulmonary Embolism
o Elevated respiratory rate can also be seen in pulmonary embolism due to impaired gas exchange and increased respiratory effort to compensate for decreased oxygen levels.
Pain
• Pulmonary Embolism
o Pain, particularly pleuritic chest pain, is a common symptom of pulmonary embolism and could be indicative of embolic obstruction in the pulmonary circulation.
Blood pressure
• Hypovolemic Shock
o The drop in blood pressure to 88/54 mm Hg is consistent with hypovolemic shock, where reduced blood volume leads to decreased perfusion and hypotension.
Mentation
• Hypovolemic Shock
o Altered mentation, such as restlessness or agitation, can be a sign of hypovolemic shock as decreased perfusion affects brain function and consciousness.
• Pulmonary Embolism
o Changes in mentation can also occur in pulmonary embolism due to hypoxemia or decreased perfusion to the brain.
Correct Answer is B
Explanation
A. Restrict fluid intake: This would not be appropriate for hypernatremia, as fluid intake should generally be increased to help dilute serum sodium levels.
B. Restrict sodium intake: This is correct as reducing sodium intake helps manage hypernatremia by decreasing the amount of sodium in the bloodstream.
C. Administer a potassium supplement: Potassium supplementation is not indicated for hypernatremia and could lead to imbalances.
D. Administer a laxative: A laxative is not relevant for managing hypernatremia and does not address the underlying issue of high sodium levels.
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