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.

Answer and Explanation

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.

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Correct Answer is B

Explanation

A. "Tell me more about your partner.":

While understanding the client's feelings about their partner is important, the immediate concern is the client's statement expressing a desire to die. Therefore, focusing on the client's thoughts about self-harm (Option B) takes precedence in ensuring their safety.

B. "Have you thought about harming yourself?":

This response is appropriate because it directly addresses the client's statement expressing a desire to die. It opens a dialogue about the client's thoughts and intentions related to self-harm, allowing the nurse to assess the client's risk and initiate appropriate interventions.

C. "Why did you stop taking your medication?":

While understanding the reasons behind medication non-compliance is important, the immediate concern is the client's current statement indicating suicidal ideation. Exploring the client's medication adherence can be addressed after addressing the acute safety concern.

D. "You should discuss these feelings with your provider.":

This response might be seen as avoiding the client's immediate expression of distress. It is important for the nurse to directly assess the client's risk and initiate appropriate interventions rather than deferring the responsibility to another healthcare provider at this moment.

A. Supine in low-Fowler's position B. Side-lying with the right side of the chest elevated C. Right lateral in Trendelenburg position D. Prone with pillows under the lower extremities

Correct Answer is C

Explanation

a. Supine in low-Fowler's position - This position is not effective for draining the left lower lobe.

b. Side-lying with the right side of the chest elevated - This position would not effectively drain the left lower lobe.

c. Right lateral in Trendelenburg position - This is correct. Placing the client on their right side with the chest lower than the hips (Trendelenburg position) helps gravity assist in draining secretions from the left lower lobe.

d. Prone with pillows under the lower extremities - This position would not be effective for draining the left lower lobe.

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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?

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Naxlex Comprehensive Predictor Exams

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