A home health nurse is conducting a home-safety risk appraisal for an older adult client. Which of the following findings should the nurse identify as a safety risk for the client? (Select all that apply.)

Water heater temperature 54.4°C (130° F)

Electric cords behind furniture

Bathtub with rails

Raised toilet seats

Throw rugs

Answer and Explanation

Correct Answer : A,B,E

A. Water heater temperature 54.4°C (130° F):

This water heater temperature is too high and poses a scalding risk. The recommended temperature setting for water heaters is generally below 49°C (120° F) to prevent burns.

B. Electric cords behind furniture:

Placing electric cords behind furniture can create tripping hazards. It is safer to have cords organized and placed away from areas where the client may walk.

C. Bathtub with rails:

Having a bathtub with rails is a safety feature that can assist the client in getting in and out of the bathtub safely. It is not a safety risk.

D. Raised toilet seats:

Raised toilet seats are often recommended for older adults to facilitate safe and easier use of the toilet. They are not a safety risk when used appropriately.

E. Throw rugs:

Throw rugs can be a tripping hazard, especially for older adults who may have mobility issues. They should be secured or removed to prevent falls.

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Correct Answer is B

Explanation

A. "The doctor can best help you with that after your physical examination."

This response implies that a physical examination is necessary before discussing contraception, which may not be accurate. Contraceptive counseling can often occur without a physical examination, and the nurse can provide initial guidance based on the information available.

B. "Before I can help you with that question, I need to know more about your sexual activity."

This response is appropriate because it acknowledges the need for more information to provide personalized advice. It respects the individual's privacy while recognizing that different contraceptive methods may be suitable based on factors like sexual activity, health history, and personal preferences.

C. "You are so young. Are you sure you are ready for the responsibilities of a sexual relationship?"

This response may come across as judgmental and could potentially discourage open communication. It's essential to maintain a non-judgmental and supportive attitude when discussing sexual health with adolescents. Instead of questioning their readiness, the focus should be on providing accurate information and support.

D. "Because of your age, we need your parents' consent for an examination, and then we'll talk."

This response may not be appropriate as it suggests a potential barrier to seeking advice about contraception. Many jurisdictions allow adolescents to receive confidential reproductive health services, including contraception, without parental consent. Encouraging open communication and respecting confidentiality is crucial in supporting adolescents' access to reproductive healthcare.

A. Offer to request a prescription for an indwelling urinary catheter. B. Keep a night light on in the client's room. C. Put the side rails up and tell the client to call for assistance to the bathroom. D. Limit the client's fluid intake in the evening.

Correct Answer is B

Explanation

A. Offer to request a prescription for an indwelling urinary catheter.

Indwelling urinary catheters come with their own set of risks and complications. It is generally not recommended to use them solely for the purpose of preventing falls unless there are other medical indications for their use. Catheters increase the risk of infection and other complications, and their use should be based on clear medical necessity.

B. Keep a night light on in the client's room.

This option directly addresses the client's concern about falling during the night. Providing a night light in the room helps to alleviate disorientation, making it safer for the client to navigate to the bathroom. It is a practical and non-invasive intervention.

C. Put the side rails up and tell the client to call for assistance to the bathroom.

While using side rails can be a fall prevention measure, it's important to consider that they are not without risks. Side rails can lead to entrapment or injury if not used appropriately. In addition, telling the client to call for assistance is good advice, but relying solely on this instruction may not address the immediate concern of disorientation in new surroundings.

D. Limit the client's fluid intake in the evening.

While limiting fluid intake in the evening might reduce the frequency of bathroom trips, it is not the most appropriate response to the client's concern. Dehydration can lead to other health issues and should not be used as the primary strategy for fall prevention.

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A home health nurse is conducting a home-safety risk appraisal for an older adult client. Which of the following findings should the nurse identify as a safety risk for the client? (Select all that apply.)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assisting with a community program to educate adolescents about contraception. After the class, a 15-year-old girl asks the nurse which method is best for her to use. Which of the following statements is an appropriate nursing response?

Correct Answer is B

Explanation

As a nurse prepares an older adult client for bed on the first night of her hospital stay, the client says, "I am afraid that I may fall getting to the bathroom during the night. I tend to get a bit disoriented in new surroundings." Which of the following actions should the nurse take?

Correct Answer is B

Explanation

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