The nurse is checking the home environment of a client for safety hazards.
Which of the following items require intervention by the nurse?
The television set is turned to a loud volume.
The dining room table has low chairs with no armrests.
The bedroom extension cord is placed under a heavy nightstand.
The living room contains wall-to-wall carpeting.
The Correct Answer is C
c. The bedroom extension cord is placed under a heavy nightstand.
The nurse should intervene and address the placement of the bedroom extension cord under a heavy nightstand. This poses a safety hazard as it increases the risk of electrical fire or tripping. The nurse shouldmeducate the client about the importance of using proper outlets and avoiding the use of extension cords in general, especially when they are hidden under heavy furniture.
Options a, b, and d do not require immediate intervention by the nurse:
a. The television set turned to a loud volume can be addressed by educating the client about the potential risks of prolonged exposure to loud noises and providing guidance on appropriate volume levels.
b. The presence of low chairs with no armrests in the dining room may not necessarily require immediate intervention unless there are specific safety concerns related to the client's mobility or balance. The nurse may provide general recommendations for safer seating options, especially if the client is at risk of falls or has difficulty getting up from low chairs.
d. The presence of wall-to-wall carpeting in the living room is a common feature in many homes and does not necessarily pose a safety hazard. However, the nurse may discuss general home safety measures, such as keeping the carpet clean and free of tripping hazards, especially for clients with mobility issues.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
b. Perform passive range-of-motion exercises.
During a vaso-occlusive crisis in sickle-cell disease, blood flow to certain areas of the body may be restricted, leading to pain and tissue damage. Passive range-of-motion exercises can help promote blood circulation and prevent joint stiffness and further complications. These exercises involve gently moving the child's joints through their full range of motion without active participation from the child.
Explanation for the other options:
a. Limit fluid intake during the evening: Fluid intake is important in sickle-cell disease to prevent dehydration and maintain adequate blood flow. Restricting fluid intake during a vaso-occlusive crisis can further contribute to dehydration and may worsen the crisis. It is important to encourage fluid intake unless otherwise instructed by the healthcare provider.
c. Apply cold compresses to painful areas: Cold compresses are not recommended during a vaso-occlusive crisis in sickle-cell disease. Cold temperatures can cause vasoconstriction and further worsen the blood flow to affected areas, leading to increased pain and tissue damage. Warm compresses or warm packs may be used to promote vasodilation and provide pain relief.
d. Provide a low-protein diet: A low-protein diet is not specifically indicated in the plan of care for a vaso- occlusive crisis in sickle-cell disease. Adequate protein intake is important for overall nutritional needs and tissue repair. The focus of nutritional management in sickle-cell disease is usually on a well-balanced diet that includes adequate hydration and appropriate nutrient intake.
In summary, performing passive range-of-motion exercises is an appropriate intervention to include in the
plan of care for a school-age child experiencing a vaso-occlusive crisis in sickle-cell disease.
Correct Answer is B
Explanation
b. Keep suction equipment at the client's bedside.
The nurse should plan to include keeping suction equipment at the client's bedside as an intervention for a client with Parkinson's disease. Parkinson's disease can cause dysphagia (difficulty swallowing) and an increased risk of aspiration. Having suction equipment readily available allows for prompt intervention in case of choking or aspiration episodes, ensuring the client's safety.
Explanation for the other options:
a. Restrict the client's fluid intake: Restricting the client's fluid intake is not typically indicated in the care of a client with Parkinson's disease. Adequate hydration is important for overall health and well-being. However, specific fluid restrictions may be necessary in certain situations, such as if the client has coexisting conditions like heart failure or kidney disease, which should be assessed and determined by the healthcare provider.
c. Instruct the client to look down when ambulating: In Parkinson's disease, individuals often experience a forward-flexed posture and a shuffling gait. Instructing the client to look down when ambulating is not an appropriate intervention. Instead, the nurse should encourage the client to maintain an upright posture, take smaller steps, and focus on taking deliberate and controlled movements to promote stability and reduce the risk of falls.
d. Position the client supine after eating: Positioning the client supine after eating is not recommended for a client with Parkinson's disease. This position can increase the risk of aspiration, as it may promote reflux and regurgitation of stomach contents. Instead, the nurse should advise the client to maintain an upright position, such as sitting in a chair or using a recliner with appropriate head support, to aid digestion and reduce the risk of aspiration.
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