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 C

Explanation

Rationale:
A. Having no vesicles prevents the spread of transmission: HSV-2 can be transmitted even when no visible lesions are present through asymptomatic viral shedding. The client should use barrier protection, such as condoms, during all sexual activity to reduce transmission.

B. Antibiotics are the primary treatment for this infection: HSV-2 is a viral infection, and antibiotics are ineffective against viruses. The mainstay of treatment involves antiviral medications such as acyclovir, valacyclovir, or famciclovir.

C. It is a latent infection that may reactivate periodically: HSV-2 remains dormant in nerve ganglia after the initial infection and can reactivate intermittently, leading to recurrent outbreaks triggered by stress, illness, or immunosuppression.

D. It is recommended any partners receive a vaccine to prevent this infection: There is currently no vaccine available to prevent HSV-2 infection. Prevention relies on consistent condom use, abstaining during outbreaks, and open communication with sexual partners about infection status.

A. Limit visitors to 30 min per day. B. Place the client in a semi-private room. C. Instruct visitors who are pregnant to remain 3 feet from the client. D. Wear a lead apron when providing care. E. Close the door to the client's room.

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

Explanation

Rationale:
A. Limit visitors to 30 min per day: Limiting the duration of visitors helps minimize radiation exposure to others. Only short, necessary visits are allowed, and visitors are advised to maintain a safe distance to reduce the cumulative radiation dose received during contact with the client.

B. Place the client in a semi-private room: Clients with sealed internal radiation implants should always be placed in a private room to protect others from unnecessary radiation exposure. A semi-private room would increase the risk of exposing other patients to radiation.

C. Instruct visitors who are pregnant to remain 3 feet from the client: Pregnant visitors should be instructed not to enter the client’s room at all because of the high sensitivity of the fetus to radiation exposure.

D. Wear a lead apron when providing care: The nurse must wear a lead apron while providing direct care to shield against radiation exposure. The nurse should also stand at the client’s side rather than directly in front of or behind the radiation source to minimize exposure intensity.

E. Close the door to the client’s room: Keeping the client’s door closed helps contain the radiation within the room, preventing unnecessary exposure to staff and other clients in nearby areas. It is part of the standard protective measures for clients undergoing internal radiation therapy.

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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?

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