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.

Answer and Explanation

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.

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

Explanation

Rationale:
A. "You sound like you have questions about your mom dying. Let's talk about it.": This response acknowledges the daughter’s emotional struggle and invites open dialogue. It encourages expression of thoughts and feelings, which supports coping and helps build trust.

B. "Tell me how you are feeling about your mom dying.": This therapeutic response promotes emotional expression and validates the daughter’s experience. It allows the nurse to assess the daughter’s understanding, provide reassurance, and offer emotional support.

C. "Hospice will take good care of your mom, so I wouldn't worry about that.": This response minimizes the daughter’s emotions and shuts down communication. It focuses on reassurance rather than addressing the underlying fear or uncertainty the daughter feels about her mother’s death.

D. "Let's talk about your mom's cancer and how things will progress from here.": Providing honest and compassionate information about disease progression helps the daughter prepare emotionally and practically. It also fosters understanding and reduces anxiety about the unknown aspects of dying.

E. "Tell her not to worry. She still has plenty of time left.": Offering false reassurance denies the reality of the situation and prevents the daughter from processing anticipatory grief. Such a response discourages open, honest communication between the client and family.

A. Conduct the assessment before drying the newborn. B. Check the newborn's rectal temperature every hr. C. Place the newborn in an open crib for the initial assessment. D. Cover scale with warm blankets when weighing the newborn.

Correct Answer is D

Explanation

Rationale:
A. Conduct the assessment before drying the newborn: Performing the assessment before drying exposes the newborn’s wet skin to cooler air and surfaces, increasing heat loss through evaporation, not conduction. The newborn should always be thoroughly dried immediately after birth to conserve body heat.

B. Check the newborn's rectal temperature every hr: Frequent temperature monitoring does not prevent heat loss; it only identifies hypothermia after it occurs. Additionally, rectal temperature measurement may cause mucosal injury and is not routinely recommended for newborns.

C. Place the newborn in an open crib for the initial assessment: Placing the newborn in an open crib exposes the infant to cooler air and surfaces, increasing heat loss through convection and conduction. The initial assessment should occur under a radiant warmer to maintain thermal stability.

D. Cover scale with warm blankets when weighing the newborn: Covering the scale prevents conduction heat loss, which occurs when the newborn’s skin comes into contact with cold surfaces. Using a warm blanket or pad ensures the infant’s body heat is preserved during weighing or handling.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has cancer and is being transferred to hospice care. The client's daughter tells the nurse, "I'm not sure what to say to my mom if she asks me about dying." Which of the following responses by the nurse is appropriate? (Select all that apply.)

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

Explanation

A nurse is performing a head-to-toe assessment on a newborn. Which of the following actions should the nurse take to prevent heat loss through conduction?

Correct Answer is D

Explanation

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