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.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is {"A":{"answers":"B"},"B":{"answers":"A"},"C":{"answers":"B"},"D":{"answers":"B"},"E":{"answers":"A"},"F":{"answers":"A"},"G":{"answers":"A"}}
Explanation
Rationale:
• Encourage naps during the day when client is tired: Daytime napping can interfere with nighttime sleep quality and reduce trazodone’s effectiveness in reestablishing a normal sleep pattern.
• Advise client to rise slowly from sitting position: Trazodone can cause orthostatic hypotension, particularly when therapy is initiated. Educating the client to change positions slowly helps prevent dizziness and potential falls caused by sudden drops in blood pressure.
• Instruct client to avoid foods that have been fermented or aged: This instruction applies to MAOIs due to the risk of hypertensive crisis from tyramine, but trazodone is a serotonin antagonist and reuptake inhibitor, not an MAOI.
• Encourage client to sleep until later in the morning: Oversleeping disrupts the circadian rhythm and may worsen fatigue. The goal is to maintain a stable sleep-wake cycle to enhance mood and energy regulation.
• Encourage a regular sleep-wake schedule: Establishing consistent sleep routines supports trazodone’s sedative effects and helps regulate the client’s circadian rhythm, improving overall sleep quality without disrupting normal activity patterns.
• Advise client to notify provider if pregnant: Trazodone is classified as pregnancy category C, meaning potential fetal risks exist. The client should notify the provider to evaluate the safety of continuing or adjusting medication during pregnancy.
• Encourage high-calorie finger foods: The client’s BMI has decreased, and trazodone may cause appetite suppression. Offering convenient, calorie-dense snacks helps maintain adequate nutrition and prevents further weight loss.
Correct Answer is A
Explanation
Rationale:
A. The client started working in a parking garage 3 months ago: Working in a parking garage may expose the client to exhaust fumes and carbon monoxide, which are hazardous during pregnancy. This environment increases the risk of fetal hypoxia and warrants further evaluation for occupational safety and potential exposure mitigation.
B. The client is doing 30 min of moderate exercise daily: Moderate exercise during pregnancy is generally safe and encouraged to promote maternal health, improve circulation, and reduce gestational complications. This activity does not indicate unsafe behavior.
C. The client is drinking 2.5 L of water per day: Adequate hydration is recommended during pregnancy to support maternal and fetal circulation, amniotic fluid levels, and overall health. Drinking 2.5 L per day is appropriate and does not require intervention.
D. The client last visited the dentist 4 months ago: Regular dental care is encouraged, but a visit every 4–6 months is generally considered safe and routine. This finding does not indicate unsafe behavior requiring urgent evaluation.
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