A home health nurse is evaluating a health aide for a client with Alzheimer’s Disease.
What statement by the health aide would require the nurse to re-evaluate and correct the plan of care?

I make sure all throw rugs are removed from the client’s walking path.

I document my activities with the client before I leave for the day.

If I have any questions about the plan of care, I will contact you.

I give the client his medications when the wife is grocery shopping

Answer and Explanation

The Correct Answer is D

I give the client his medications when the wife is grocery shopping. This statement would require the nurse to re-evaluate and correct the plan of care because home health aides are not allowed to administer medications in most states. Home health aides can only provide medication reminders, help put the medication into the hands of the user, or assist with self-administration of certain forms of medications.

Giving medications to the client without supervision or delegation by a registered nurse or physician is a violation of the scope of practice and could harm the client.

Choice A is wrong because removing throw rugs from the client’s walking path is a safety measure that can prevent falls and injuries for a client with Alzheimer’s disease.

Choice B is wrong because documenting activities with the client before leaving for the day is a professional responsibility that ensures continuity of care and accountability.

Choice C is wrong because contacting the nurse if there are any questions about the plan of care is a sign of good communication and collaboration that can enhance the quality of care for the client.

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Correct Answer is ["B","D"]

Explanation

Clubbing in upper digits and tripod positioning are signs of chronic obstructive pulmonary disease (COPD), a respiratory disorder that has components of chronic bronchitis and emphysema. Clubbing is a thickening and widening of the fingertips and nails due to chronic low oxygen levels in the blood. Tripod positioning is when the person leans forward and supports their arms on a table or chair to facilitate breathing.

Choice A is wrong because a BMI greater than 30% indicates obesity, which is not a specific sign of COPD, although it can worsen the condition.

Choice C is wrong because AP chest diameter of 1:1 means that the chest is as wide as it is deep, which is also known as barrel chest. This is a sign of emphysema, one of the components of COPD, but not of COPD itself.

Choice E is wrong because high amounts of energy are not associated with COPD. On the contrary, people with COPD often experience fatigue, weakness, and reduced exercise tolerance due to impaired gas exchange and respiratory muscle function.

A. A normal reaction to a position change. B. Gait belt applied. C. Orthostatic hypotension noted with dangling. D. Elevated blood sugar probable.

Correct Answer is C

Explanation

Orthostatic hypotension noted with dangling.

This means that the client’s blood pressure drops when changing position from lying down to sitting or standing. This can cause symptoms such as paleness, sweating, rapid pulse, weakness, and dizziness.

The nurse should document this finding and report it to the physician.

Choice A is wrong because a normal reaction to a position change would not cause such severe symptoms.

Choice B is wrong because the gait belt applied is not a finding but an intervention.

Choice D is wrong because elevated blood sugar probable is not a finding but a speculation.

Choice E is wrong because spot accucheck obtained is not a finding but an action.

Choice F is wrong because fear of falling expressed by a client is not a finding related to the client’s vital signs or physical condition.

Choice G is wrong because provided reassurance is not a finding but a nursing measure.

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A home health nurse is evaluating a health aide for a client with Alzheimer’s Disease. What statement by the health aide would require the nurse to re-evaluate and correct the plan of care?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is admitting a client with an exacerbation of chronic obstructive pulmonary disease. What signs would the nurse expect to observe with this client? Select all that apply.

Correct Answer is ["B","D"]

Explanation

A nurse is getting a client out of bed to ambulate for the first time. The client is pale, diaphoretic, has a pulse of 100/minute, and says, “I feel weak. Let me sit on the side of the bed for a minute.” What finding should the nurse document?

Correct Answer is C

Explanation

A client says to the nurse “I will not take the prescribed medication today.” What should be the initial action by the nurse?

A health care provider has ordered vital signs every 4 hours. The client’s 8:00 AM temperature was 99° F (37.2° C). At 10 AM, the client reported chills. A nurse takes the client’s temperature again. Which type of nursing action does this exemplify?

When a client has a nursing diagnosis of Ineffective Coping, which nursing interventions would best meet the desired outcome of demonstrating appropriate coping strategies? (Select all that apply).

A client is admitted with rule out tuberculosis. What extra safety precautions must be in place to care for this client? Select all that apply.

Which intervention should the nurse include while caring for a client who has been diaphoretic for the past six hours?

Which assessment finding would be considered normal in an elderly client?

A client admitted to the coronary care unit with an inferior wall myocardial infarction is anxious, sweating, tachypneic, and reports midsternal chest discomfort and nausea. Which nursing diagnosis is the priority?

The nurse is caring for a client at risk for a respiratory infection. Which of the following natural respiratory defense mechanisms help defend against infection? (Select all that apply).

A home health nurse is evaluating a health aide for a client with Alzheimer’s Disease.
What statement by the health aide would require the nurse to re-evaluate and correct the plan of care?