A home health nurse is assessing an older adult client’s home after providing teaching about home safety. Which of the following actions by the client indicates an understanding of the teaching?

The client covers electrical cords with a throw rug

The client set the water heater set to 49 degrees Celsius (120 degrees Farhenheit)

The client has the refrigerator set to 7.2 degrees Celsius (45 degrees Fahrenheit)

The client has a standard height toilet seat in the bathroom

Answer and Explanation

The Correct Answer is B

A. The client covers electrical cords with a throw rug: This action is unsafe. Placing a throw rug over electrical cords poses a fire hazard and could lead to tripping. Electrical cords should be secured and kept out of walkways to prevent accidents.

B. The client set the water heater to 49 degrees Celsius (120 degrees Fahrenheit): The water heater should be set to a maximum temperature of 49°C (120°F) to prevent scalding injuries, which are a concern for older adults whose skin may be more sensitive. Temperatures higher than this increase the risk of burns.

C. The client has the refrigerator set to 7.2 degrees Celsius (45 degrees Fahrenheit): This temperature is too high. A refrigerator should be set at or below 4°C (40°F) to properly preserve food and prevent bacterial growth. Setting the refrigerator to 7.2°C (45°F) can result in foodborne illnesses.

D. The client has a standard height toilet seat in the bathroom: This may be inadequate for older adults, particularly those with mobility issues. A raised toilet seat may be recommended for better comfort and safety, as it reduces the risk of falls while sitting down or standing up.

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Correct Answer is A

Explanation

a. Close the documentation program on the computer:

This action is appropriate as it immediately stops unauthorized access to the client's medical information and prevents further viewing of protected health information (PHI).

b. Find out which staff member left the documentation program on the screen:

While it's important to identify any staff member who may have left the documentation program open, addressing this issue should not be the first priority. The immediate concern is stopping the unauthorized access to the client's information and ensuring that the visitor is aware of the confidentiality breach.

c. Tell the charge nurse that the visitor viewed a client’s protected health information:

Notifying the charge nurse about the incident is important, but it should not be the first action taken. The priority is to address the immediate breach of confidentiality and prevent further unauthorized access to the client's information.

d. Inform the visitor that client records are confidential:

This action may be appropriate after addressing the immediate breach of confidentiality. However, it should not be the first action taken as it does not immediately stop the unauthorized access to the client's information.

A. “You should contact the provider about your wishes to your family member.” B. “You should speak with the facility’s ethics committee about your concerns.” C. “We’ll need to have the nursing supervisor review the client’s advance directives.” D. “As the health care surrogate, the client’s partner can make this decision.”

Correct Answer is D

Explanation

a. "You should contact the provider about your wishes for your family member."

While the provider may ultimately be involved in decision-making, it's important for the nurse to address the conflicting wishes and provide guidance on the appropriate steps to take in such situations.

b. "You should speak with the facility’s ethics committee about your concerns."

In cases of conflicting wishes or ethical dilemmas, involving the ethics committee can be beneficial. However, this response might not address the immediate need for clarification and guidance.

c. "We’ll need to have the nursing supervisor review the client’s advance directives."

Reviewing advance directives with the nursing supervisor is a reasonable step to ensure that the client's wishes are documented and followed. However, it might not directly address the conflicting wishes or provide immediate resolution.

d. "As the health care surrogate, the client’s partner can make this decision."

This is the correct response. The health care surrogate, appointed by the client or legally recognized as such, has the authority to make medical decisions on behalf of the unconscious client. It's important to follow the client's advance directives and legal designations regarding

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A home health nurse is assessing an older adult client’s home after providing teaching about home safety. Which of the following actions by the client indicates an understanding of the teaching?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse enters the hallway and discovers a visitor looking at a client’s medical information on a computer. Which of the following actions should the nurse take first?

Correct Answer is A

Explanation

Correct Answer is D

Explanation

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