During a home visit, the nurse observes an elderly patient trying to walk to the bathroom. The patient appears unstable and clings to furniture while refusing any help.
What action should the nurse take?
Suggest that the patient get a walker.
Encourage the patient to acquire a medical alert device.
Ensure the patient’s privacy while in the bathroom.
Identify potential safety hazards in the home.
The Correct Answer is D
Answer and explanation
The correct answer is Choice D.
Choice A rationale
While suggesting that the patient get a walker might help with mobility, it does not directly address the safety concerns in the home environment.
Choice B rationale
A medical alert device could be beneficial in case of emergencies, but it does not prevent the risk of falls or accidents in the home.
Choice C rationale
Ensuring the patient’s privacy is important, but it does not address the immediate safety concerns observed by the nurse.
Choice D rationale
Identifying potential safety hazards in the home is the most immediate and effective action the nurse can take. By doing this, the nurse can work with the patient and their family to make necessary changes to improve safety and prevent falls.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Answer and explanation The correct answer is D. Choice A rationale
Staying with someone for 10 hours post-injection is not a standard recommendation after receiving the Hepatitis B Vaccine (HBV). The vaccine is generally well-tolerated, and serious side effects are rare.
Choice B rationale
While it can be comforting to have a family member present during medical procedures, it is not necessary for the final injection of the HBV series.
Choice C rationale
While it is important to encourage vaccination among all eligible individuals, the immediate concern after healthcare workers receive the HBV is not about their family members’ vaccination status.
Choice D rationale
Regular monitoring of immunization levels is important after receiving the HBV series. This is because healthcare workers are at a higher risk of exposure to Hepatitis B, and ensuring immunity is crucial for their safety.
Correct Answer is C
Explanation
Answer and explanation
The correct answer is Choice C.
Choice A rationale
A 65-year-old aide working in a nursing home is at high risk of contracting and spreading influenza due to their exposure to a vulnerable population. Therefore, they should be prioritized for vaccination.
Choice B rationale
An 8-year-old girl with poorly-controlled asthma is also at high risk for complications from influenza and should be prioritized for vaccination.
Choice C rationale
A 60-year-old client with diabetes is at increased risk for complications from influenza. However, their agoraphobia (fear of crowds) might make them less likely to be exposed to the
virus compared to the other individuals. Therefore, they could be advised to return to the clinic when more vaccines are available.
Choice D rationale
An 80-year-old resident in an Alzheimer’s unit is at high risk due to their age and living situation. They should be prioritized for vaccination.
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