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. Decreased serum uric acid: In preeclampsia, serum uric acid levels are elevated, not decreased, due to reduced renal clearance and tissue ischemia. Increased uric acid is often one of the earliest laboratory indicators of preeclampsia.
B. Increased protein in urine: Proteinuria is a key diagnostic feature of preeclampsia resulting from glomerular endothelial damage that increases permeability to proteins. The presence of protein in the urine reflects kidney involvement and helps distinguish preeclampsia from gestational hypertension.
C. Increased platelet count: Preeclampsia is typically associated with thrombocytopenia (low platelet count) due to platelet aggregation and consumption within damaged blood vessels. An increased platelet count would not be expected in this condition.
D. Decreased BUN: In preeclampsia, renal perfusion is reduced, leading to elevated BUN and creatinine levels. A decrease in BUN would indicate improved kidney function, which is inconsistent with the pathophysiology of preeclampsia.
Correct Answer is ["A","B","D"]
Explanation
Rationale:
A. Hypothermia: Hypothermia increases metabolic demand and glucose utilization in newborns, making them more susceptible to hypoglycemia. Maintaining normal body temperature is crucial for preventing low blood glucose levels.
B. Maternal diabetes: Infants born to mothers with diabetes are at higher risk for hypoglycemia due to fetal hyperinsulinemia. After birth, the excess insulin can cause rapid drops in blood glucose.
C. Anemia: While anemia affects oxygen-carrying capacity, it is not a direct risk factor for neonatal hypoglycemia. Blood glucose regulation is not primarily impacted by red blood cell count.
D. Prematurity: Premature infants have limited glycogen stores and immature glucose regulation, increasing the risk for hypoglycemia. They may require closer glucose monitoring and early feeding interventions.
E. Thrombocytopenia: Low platelet count does not affect glucose metabolism and is not a recognized risk factor for neonatal hypoglycemia.
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