A community health nurse is performing a home visit for a client and is evaluating the home environment for safety. Which of the following findings would indicate to the nurse that the client has a proper understanding of safety in the home?
A single light fixture hangs along the sidewalk to the house.
A small area rug is placed at the front door.
The batteries in the smoke alarms are changed annually.
The water heater is set at 54° C (129.2° F).
The Correct Answer is C
A. A single light fixture along the sidewalk may not provide adequate lighting, increasing the risk of falls, and does not reflect proper home safety.
B. A small area rug at the front door can create a tripping hazard, indicating a need for improved safety measures.
C. Changing the batteries in the smoke alarms annually demonstrates that the client is maintaining functional smoke detectors, which is a key aspect of home safety. Regular maintenance of smoke alarms helps prevent fire-related injuries.
D. While a water heater set at 54° C (129.2° F) can prevent scalding, current safety recommendations suggest a slightly lower setting (around 49° C / 120° F) to maximize safety, so this is not the best indicator of proper understanding.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Rationale:
A. Stagger care to avoid taking more than one specimen at a time: While staggering procedures can reduce cumulative stress, it is not a primary strategy for obtaining cooperation from a preschooler for a single blood draw.
B. Apply vapocoolant spray immediately prior to collecting the specimen: Vapocoolant sprays can help numb the skin, but their use in preschoolers requires caution, as sudden cold sensations may startle or frighten the child. Additional preparation and explanation are necessary for acceptance.
C. Ask the parents to leave the room prior to collecting the blood specimen: Preschoolers often feel more secure and cooperative when a parent is present. Removing the parent may increase anxiety and resistance to the procedure, so parental support is usually encouraged.
D. Demonstrate the use of the equipment for the child: Preschoolers benefit from simple, age-appropriate explanations and demonstrations of medical equipment. Showing how the equipment works helps reduce fear, build trust, and increase cooperation during the blood draw.
Correct Answer is A
Explanation
Rationale:
A. Sunken fontanels and dry mucous membranes: These findings indicate moderate to severe dehydration, which can quickly become life-threatening in an infant. Prompt notification of the provider is essential to initiate fluid replacement and prevent complications such as hypovolemic shock.
B. Temperature 38° C (100.4° F) and pulse rate 124/min: A low-grade fever and mildly elevated pulse are common in gastroenteritis and typically do not require immediate reporting unless accompanied by other concerning symptoms like poor perfusion or lethargy.
C. Pale and a 24-hr fluid deficit of 30 mL: A fluid deficit of 30 mL over 24 hours is minimal in an infant and not immediately concerning. Monitoring should continue, but urgent reporting is not necessary for this level of deficit.
D. Decreased appetite and irritability: These are expected symptoms of gastroenteritis in infants and can be managed with routine supportive care and monitoring. They are not specific indicators of severe dehydration requiring immediate provider intervention.
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