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. "You sound frustrated, tell me more about this feeling." This response validates the patient’s feelings and opens up a discussion about their emotions, which provides support and helps address their psychological needs.

B. "You remind me of my mother, she is always frustrated when she is ill." This response is not focused on the patient’s needs and shifts attention away from their concerns.

C. "I am concerned about your mental health; I will call your family." While mental health is important, calling the family without first addressing the patient’s immediate concerns might feel intrusive or premature.

D. "You need to be more careful after this stroke or you could fall." This response addresses safety but does not provide emotional support or acknowledge the patient’s feelings of frustration.

A. Hemiparesis B. Hypertonicity C. Crepitation D. Paraplegia

Correct Answer is D

Explanation

A. Hemiparesis: Hemiparesis refers to weakness on one side of the body, which does not fully describe the inability to move only the legs.

B. Hypertonicity: Hypertonicity refers to increased muscle tone or stiffness, not the inability to move legs.

C. Crepitation: Crepitation refers to a crackling or popping sound in the joints, not the inability to move legs.

D. Paraplegia: Paraplegia refers to the paralysis of the lower half of the body, including the legs, which fits the description of the patient’s condition.

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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

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Correct Answer is A

Explanation

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Explanation

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