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.

Answer and Explanation

Correct Answer : C,D

Choice A rationale: A shuffling gait increases fall risk but does not directly impair ability to perform foot care or toenail trimming, so UAP assignment is not primarily indicated here.

Choice B rationale: Urinary incontinence affects bladder control, not manual dexterity or safety during foot care. It does not necessitate UAP assistance for toenail trimming or routine foot care.

Choice C rationale: Syncope when bending increases risk of fainting during foot care tasks, making independent toenail trimming unsafe. UAP support ensures safety and prevents injury during routine care.

Choice D rationale: Hand tremors impair fine motor control, making toenail trimming difficult and unsafe. UAP assistance is indicated to prevent injury and ensure proper routine foot care.

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Correct Answer is B

Explanation

Choice A reason: Slip-on rubber shower shoes are not recommended as they do not provide the necessary support or stability for a client with weakness on one side.

Choice B reason: Tennis shoes with Velcro are ideal as they offer good support and are easy to fasten, which is beneficial for a client with one-sided weakness and potentially limited dexterity.

Choice C reason: Leather-soled loafers can be slippery and do not offer the snug fit and support needed for safe ambulation post-stroke.

Choice D reason: Rubber-soled slippers may provide some grip but typically do not offer the structured support that is necessary for a client with post-stroke weakness.

A. Assess for sources of pain other than the surgical site. B. Change to a behavioral pain scale. C. Give a dose of 2.5 mg of morphine. D. Refer to social work for drug-seeking behavior. E. Bring an opioid reversal agent to the bedside. F. Lead the client in guided imagery. G. Consult with the surgeon about the pain level. H. Helping the client walk around the room.

Correct Answer is ["A","C","G","H"]

Explanation

Choice A reason:
The increase in heart rate from 78 to 118 beats per minute, along with the increase in pain rating from 3 to 8, suggests that the client may be experiencing pain from a source other than the surgical site. It is important to assess for other potential sources of pain to ensure comprehensive pain management.
Choice B reason:
Changing to a behavioral pain scale is not indicated in this scenario. The numerical pain scale is a standard and effective method for assessing pain levels, and there is no indication that the client has difficulty communicating her pain using this scale.
Choice C reason:
Given that the client's pain rating increased to 8, which is above the threshold of 4 on the pain scale, administering a dose of 2.5 mg of morphine as per the orders is appropriate to manage her pain.
Choice D reason:
Referring to social work for drug-seeking behavior is not supported by the information provided. The client's increased pain rating and heart rate suggest a legitimate need for pain management rather than drug-seeking behavior.
Choice E reason:
Bringing an opioid reversal agent to the bedside is not indicated unless there is a concern for opioid overdose, which is not suggested by the information provided.
Choice F reason:
While guided imagery can be a helpful adjunct for pain management, it is not the primary intervention needed at this time given the client's significant increase in pain and heart rate.
Choice G reason:
Consulting with the surgeon about the client's increased pain level is important to rule out any complications from the surgery and to discuss further pain management strategies.
Choice H reason:
Assisting the client to walk around the room may help in pain management and is part of the postoperative care plan to increase walking distance. However, it should be done cautiously considering the client's current pain level.

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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.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is teaching a spouse how to care for a client who recently had a stroke and has residual weakness on the right side. Which style of shoes should the nurse recommend the client wear when ambulating with the spouse's assistance?

Correct Answer is B

Explanation

Patient Data Exhibits Based on the trending heart rate and pain score, what should the nurse do? Select all that apply.

Correct Answer is ["A","C","G","H"]

Explanation

The nurse is preparing an in-service on the Health Insurance Portability and Accountability Act (HIPAA) violations. Which example should the nurse use to demonstrate a HIPAA violation?

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