A home health nurse is completing a home safety visit for a client who had a cerebrovascular accident (CVA). Which of the following actions should the nurse take?

Set the water heater to 54.4° C (130° F).

Replace burned-out light bulbs.

Run extension cords under throw rugs.

Ensure the client wears soft-soled slippers.

Answer and Explanation

The Correct Answer is B

Home safety is a critical component of care for clients who have had a Cerebrovascular accident because they often experience weakness, impaired balance, visual deficits, and decreased coordination. These limitations increase the risk of falls and injuries in the home environment. The nurse’s role is to identify and correct hazards that could contribute to accidents while promoting independence and safety. Environmental modifications are key to reducing preventable harm.

Rationale:
A. Setting the water heater to 54.4°C (130°F) is unsafe because it increases the risk of thermal injury or burns, especially in clients with sensory or mobility impairments. The recommended safe setting is typically lower (around 49°C/120°F) to prevent scalding injuries. This does not promote safety.

B. Replacing burned-out light bulbs is an appropriate safety intervention because adequate lighting reduces the risk of falls and improves mobility in clients with neurological deficits. Good visibility is essential for clients recovering from stroke who may have impaired balance, coordination, or visual field deficits. This directly enhances environmental safety.

C. Running extension cords under throw rugs is unsafe because it creates a tripping hazard and increases the risk of falls. Additionally, covering cords can lead to overheating and potential fire hazards. This practice should be avoided in home safety planning.

D. Ensuring the client wears soft-soled slippers may improve comfort but does not provide optimal safety if the footwear lacks proper support or traction. In stroke clients, supportive, non-slip footwear is recommended to reduce fall risk. Soft slippers may actually increase instability if they do not fit securely.

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Correct Answer is C

Explanation

Neonatal jaundice assessment using serum bilirubin testing is performed to evaluate elevated bilirubin levels in newborns. This condition commonly occurs due to the immature hepatic system of the newborn, which is still developing its ability to conjugate and excrete bilirubin. Increased breakdown of fetal red blood cells after birth contributes to a higher bilirubin load. Understanding the physiologic basis of neonatal jaundice helps parents understand why monitoring is necessary even in otherwise healthy infants.

Rationale:
A. Having four bowel movements in the first day of life is not a risk factor for elevated bilirubin levels; in fact, frequent stooling helps eliminate bilirubin from the body through the gastrointestinal tract. Delayed stooling, not increased bowel movements, is associated with higher risk of jaundice. This does not explain the need for bilirubin testing.

B. Congenital dermal melanocytosis is a benign pigmentation condition seen in newborns, especially those of certain ethnic backgrounds. It has no relationship to bilirubin metabolism or jaundice risk. Therefore, it does not justify the need for serum bilirubin testing.

C. The newborn’s liver is physiologically immature and has a reduced ability to conjugate and eliminate bilirubin produced from normal red blood cell breakdown. This leads to accumulation of unconjugated bilirubin in the bloodstream, resulting in jaundice. This is the primary reason serum bilirubin levels are monitored in newborns.

D. Breastfeeding is not an indication to stop or supplement with formula in most cases of neonatal jaundice. Although early breastfeeding jaundice can occur due to low intake, breastfeeding is generally encouraged. Routine formula supplementation is not recommended unless specifically indicated based on clinical assessment and bilirubin levels.

A. "You can expect to be drowsy after taking this medication." B. "The medication will help open up your airways so you can breathe easier." C. "The medication will help thin the mucus your airways produce." D. "You must wait 10 seconds between each inhalation."

Correct Answer is B

Explanation

Bronchitis involves inflammation of the bronchial tubes, often leading to airway narrowing, mucus production, and breathing difficulty. Medications such as bronchodilators are commonly prescribed to relieve bronchospasm and improve airflow. Albuterol is a short-acting beta2 agonist used to rapidly relax airway smooth muscles. Patient education focuses on its mechanism of action, proper use, and expected effects.

Rationale:
A. “You can expect to be drowsy after taking this medication.” Albuterol typically causes stimulation of the sympathetic nervous system rather than sedation. Common effects include nervousness, tremors, and tachycardia. Drowsiness is not an expected or therapeutic effect of this medication.

B. “The medication will help open up your airways so you can breathe easier.” This correctly describes the action of albuterol. It stimulates beta2-adrenergic receptors in bronchial smooth muscle, leading to bronchodilation. This reduces airway resistance and improves airflow, making breathing easier for clients with bronchitis or other obstructive airway conditions.

C. “The medication will help thin the mucus your airways produce.” Albuterol does not act as a mucolytic. It does not change the consistency of secretions but instead relaxes bronchial smooth muscle. Medications like expectorants or hydration are used to assist mucus clearance.

D. “You must wait 10 seconds between each inhalation.” Proper inhaler technique generally requires waiting about 1 minute between puffs to allow adequate drug deposition and absorption. The statement does not reflect correct inhalation spacing guidelines and may indicate misunderstanding of proper inhaler use.

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A home health nurse is completing a home safety visit for a client who had a cerebrovascular accident (CVA). Which of the following actions should the nurse take?

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Naxlex Comprehensive Predictor Exams

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Correct Answer is C

Explanation

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Correct Answer is B

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