The home health nurse is reviewing the personal care needs of an older adult client who lives alone. What client assessment finding(s) indicate(s) the need to assign an unlicensed assistive personnel (UAP) to provide routine foot care and has the client's toenails? Select all that apply.
Shufling gait.
Urinary incontinence.
Syncope when bending.
Hand tremors.
Correct Answer : A,C,D
The correct answer is Choice A, Choice C, and Choice D.
Choice A rationale: A shuffling gait can indicate mobility issues, making it difficult for the client to safely perform foot care and toenail clipping. This increases the risk of falls and injuries.
Choice B rationale: Urinary incontinence does not directly affect the ability to perform foot care or toenail clipping. It is more related to bladder control issues.
Choice C rationale: Syncope when bending suggests that the client may experience dizziness or fainting when bending over, making it unsafe for them to perform foot care and toenail clipping.
Choice D rationale: Hand tremors can make it challenging for the client to handle nail clippers or other tools needed for foot care, increasing the risk of injury.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A reason: While the client's medical history and admission assessment provide valuable information, they do not directly measure the current pain experience.
Choice B reason: Vital signs can indicate pain but are not a definitive measure of pain severity as they can be influenced by other factors.
Choice C reason: The frequency of analgesic administration may suggest the level of pain control but does not measure the current pain intensity experienced by the client.
Choice D reason: Asking the client to describe the intensity of the pain is the most direct and effective way to assess pain severity. Pain is subjective, and the client's self-report is considered the gold standard for pain assessment.
Correct Answer is B
Explanation
Choice A reason: While medication shortages can occur, this is not the typical reason for delivering a partial supply of medication for home health care.
Choice B reason: Daptomycin is an antibiotic that has a limited shelf life after it is mixed or reconstituted. This is why pharmacies often deliver only a portion of the doses to ensure the medication remains effective.
Choice C reason: Notifying the healthcare provider is necessary if there is a discrepancy in medication delivery that cannot be explained by standard pharmacy practices.
Choice D reason: Although instructions for medication administration may change, this is not the usual reason for a pharmacy to deliver a partial supply of medication.
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