A home health nurse is planning care for a client who has right-sided weakness following a recent cerebrovascular accident. The client reports feeling unsteady when walking. Which of the following interventions should the nurse include?
Obtain a prescription to refer the client to physical therapy.
Instruct the client to wear sandals when ambulating.
Encourage the client to dim the lights in hallways.
Instruct the client to place throw rugs on bathroom floors.
The Correct Answer is A
Rationale:
A. Obtain a prescription to refer the client to physical therapy: A referral to physical therapy is appropriate because therapists can design individualized exercises to improve balance, coordination, and strength. This intervention promotes safe mobility, enhances independence, and reduces fall risk for clients with post-stroke weakness.
B. Instruct the client to wear sandals when ambulating: Sandals do not provide adequate foot support or traction and increase the risk of tripping or falling. Clients with right-sided weakness should wear well-fitting, non-skid shoes to ensure safety and stability during ambulation.
C. Encourage the client to dim the lights in hallways: Poor lighting impairs visibility and increases the risk of falls, especially for clients with weakness or gait instability. Adequate illumination in hallways and pathways is essential for safety during ambulation.
D. Instruct the client to place throw rugs on bathroom floors: Throw rugs are a major fall hazard due to their tendency to slip or bunch up. The nurse should advise removing rugs or securing them with non-slip backing to create a safe, stable walking environment.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Rationale:
A. Wrap their arms under the client's axilla to transfer the client: Manually lifting a heavy, dependent client by placing arms under the axilla is unsafe and can cause serious musculoskeletal injuries to both the nurse and the client.
B. Use a powered lift to transfer the client: A powered mechanical lift is the safest and most appropriate method for transferring a 136-kg (300-lb) client who cannot assist. It prevents strain on healthcare workers, reduces the risk of falls, and ensures a smooth, controlled transfer from bed to chair.
C. Use a gait belt to transfer the client: A gait belt is used only for clients who can bear some weight and actively assist in the transfer. Since this client is unable to help, using a gait belt would not provide adequate support or safety during the transfer process.
D. Use a sliding board to transfer the client: Sliding boards are designed for clients who have upper body strength and can assist by lifting or shifting themselves during the transfer. In this case, the client’s inability to assist makes a powered lift the only safe and feasible option.
Correct Answer is A
Explanation
Rationale:
A. "Schedule rest periods during the day.": Fatigue is a common symptom of multiple sclerosis. Scheduling rest periods helps conserve energy, prevent exacerbation of symptoms, and improve overall functioning without overtaxing the client.
B. "Soak in a hot bath.": Heat can worsen multiple sclerosis symptoms by temporarily increasing nerve conduction delays. Hot baths may trigger fatigue or weakness and are generally discouraged.
C. "Perform aerobic activities three times per week.": While gentle exercise is beneficial, intense aerobic activity can exacerbate fatigue and heat sensitivity in clients with multiple sclerosis. Exercise should be balanced with rest periods.
D. "Have your partner complete activities of daily living for you.": Encouraging total dependence can reduce independence and self-efficacy. Clients should perform activities within their capacity to maintain function while pacing themselves appropriately.
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