The nurse is caring for a client that fell at home and is planning to move in with their adult child. Which of the following statements, by the client, would require immediate follow up by the nurse?

"I will try to make myself useful while I am in their home."

"My adult child has been preparing my grandchildren for my arrival."

"I will miss my home that I lived in for so long."

"My other adult child is willing to help me too."

Answer and Explanation

The Correct Answer is C

A. "I will try to make myself useful while I am in their home." This statement reflects a positive attitude and willingness to contribute, which does not require immediate follow-up.

B. "My adult child has been preparing my grandchildren for my arrival." This statement indicates that preparations are being made, which is generally a good sign and does not require immediate follow-up.

C. "I will miss my home that I lived in for so long." This statement requires immediate follow-up because it may indicate emotional distress or difficulty adjusting to the new living situation. The nurse should assess the client’s feelings and provide support to help them cope with the transition.

D. "My other adult child is willing to help me too." This statement is positive and indicates additional support, which is generally reassuring and does not require immediate follow-up.

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Correct Answer is A

Explanation

A. Ask the patient to try to stand up independently to assess the patient's strength first. This action is inappropriate as it may put the patient at risk of falling or injury. The patient should be assisted rather than asked to stand independently.

B. Remind the patient to look up to ensure good positioning when standing up. This is a correct action. Looking up helps the patient maintain better posture and balance when standing.

C. Allow the patient to dangle at the edge of the bed before standing to assess for feelings of dizziness. This is appropriate as it helps to identify any dizziness or orthostatic hypotension before the patient attempts to stand.

D. Assess the patient for any numbness or tingling in the extremities. This is also appropriate as it helps to identify any neurological issues that could affect the patient's ability to stand and transfer safely.

A. "Have you been trying to lose weight?" B. "You must take care of yourself or you will not be able to care for your partner." C. "What are some things you are doing to take care of yourself?" D. "It is often easy to lose weight when we become busy and distracted."

Correct Answer is C

Explanation

A. "Have you been trying to lose weight?" This response does not address the caregiver’s concern about losing weight due to lack of time and may seem to dismiss their situation.

B. "You must take care of yourself or you will not be able to care for your partner." While this statement is true, it may be perceived as accusatory and could lead to feelings of guilt or resentment.

C. "What are some things you are doing to take care of yourself?" This is a good response as it encourages the caregiver to think about their self-care practices and opens a dialogue about their well-being.

D. "It is often easy to lose weight when we become busy and distracted." This response might minimize the caregiver’s concern and does not provide practical support or solutions.

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The nurse is caring for a client that fell at home and is planning to move in with their adult child. Which of the following statements, by the client, would require immediate follow up by the nurse?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is teaching a student nurse how to assist a patient admitted for generalized weakness, to transfer from bed to a chair. The patient has not been out of bed for several days. Which of the following actions by the student nurse requires further teaching?

Correct Answer is A

Explanation

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Correct Answer is C

Explanation

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