A home health nurse is assessing the home environment of an older adult client who has osteoporosis. For which of the following findings should the nurse intervene?
The hot water heater is set to 47° C (117° F).
Grab bars are installed in the shower.
There is an area rug covering a tile floor.
Prescriptions are stored in a medication organizer.
The Correct Answer is C
A. The hot water heater is set to 47° C (117° F). This temperature is within a safe range to prevent burns while ensuring adequate hot water for hygiene.
B. Grab bars are installed in the shower. Grab bars provide support and help prevent falls in older adults, especially those with osteoporosis who are at higher risk for fractures.
C. There is an area rug covering a tile floor. Area rugs are a significant tripping hazard, especially for older adults with osteoporosis, as a fall could lead to fractures. The nurse should intervene to recommend removing or securing the rug to reduce the risk of falls.
D. Prescriptions are stored in a medication organizer. A medication organizer helps older adults manage their medications effectively and reduces the risk of missed or incorrect doses.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Whisper a series of words softly into one ear.
Explanation: Whispering words into one ear is not part of Weber's test. This action is more relevant to the assessment of hearing acuity and not the lateralization of sound. Weber's test focuses on the perception of sound in relation to both ears, not the ability to hear whispered words.
B. Place an activated tuning fork in the middle of the client's forehead.
Explanation: In Weber's test, a tuning fork is placed in the middle of the client's forehead. The test is designed to assess whether sound lateralizes (moves) to one ear or is heard equally in both ears. If the client perceives the sound more in one ear than the other, it may indicate a hearing imbalance or issue.
C. Deliver a series of high-pitched sounds at random intervals.
Explanation: Delivering high-pitched sounds at random intervals is not part of Weber's test. Weber's test involves a single action – placing an activated tuning fork in the middle of the client's forehead. The purpose is to determine if the client perceives the sound equally in both ears or if there is lateralization. Random intervals and high-pitched sounds are not specified components of this test.
D. Hold an activated tuning fork against the client's mastoid process.
Explanation: While holding a tuning fork against the mastoid process is part of another hearing test called the Rinne test, it is not the appropriate action for the Weber's test. The Rinne test compares air conduction (using the tuning fork near the ear) to bone conduction (using the tuning fork against the mastoid process) to evaluate hearing in each ear. In Weber's test, we are specifically interested in lateralization of sound, not comparing air and bone conduction.
Correct Answer is B
Explanation
A. Gown:
- After removing gloves, the gown should be taken off. The gown is considered the second most contaminated item. It is important to avoid contact with the outer surface of the gown while removing it.
B. Gloves:
- Gloves should be removed first because they are the most likely part of the PPE to be contaminated. Care should be taken to avoid touching the outside of the gloves, and they should be disposed of properly.
C. Mask:
- The mask is removed next. Care should be taken to handle the mask by the ties or ear loops without touching the front surface. Removing the mask last helps protect the nurse from potential respiratory droplets on the mask.
D. Eyewear/Face Shield:
- Eyewear or face shield is removed last. Similar to the other components, it should be handled carefully to prevent self-contamination. This step helps protect the eyes and face from any potential splashes or airborne particles.
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