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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Related Questions
Correct Answer is D
Explanation
Rationale:
A. Obtain a 12-lead ECG for the client: An ECG is important to assess for myocardial ischemia or infarction, but it should be done after immediate measures are taken to reduce myocardial oxygen demand.
B. Administer sublingual nitroglycerin to the client: Nitroglycerin helps relieve chest pain by dilating coronary arteries, but it should be given only after the client is safely seated or resting to prevent hypotension or injury.
C. Measure the client's vital signs: Vital signs provide valuable baseline data, but addressing the client’s immediate safety and reducing cardiac workload takes priority.
D. Have the client stop walking and sit down: Stopping activity decreases oxygen demand on the heart and prevents worsening ischemia or collapse, making it the first and most critical action.
Correct Answer is B
Explanation
Rationale:
A. "Avoid sexual intercourse for 7 days after receiving treatment.": HPV infections often persist in epithelial tissue even after visible lesions are treated, meaning transmission can still occur. Avoiding sexual contact for only 7 days does not eliminate the risk of spreading the virus.
B. "Obtain all recommended immunizations.": Receiving the HPV vaccine is the most effective method of preventing sexual transmission. The vaccine protects against high-risk HPV strains associated with cervical, anal, and oropharyngeal cancers, as well as genital warts. It is most effective when administered before sexual activity begins.
C. "Apply imiquimod ointment to any perineal ulcers.": Imiquimod is used to treat external genital warts caused by HPV, not perineal ulcers. Its use does not prevent infection or transmission and should only be applied to intact wart tissue under provider supervision.
D. "Undergo laser therapy to remove any lesions.": Laser therapy can remove visible warts but does not eradicate the virus itself. While it reduces the number of infectious lesions, HPV can still be transmitted through microscopic viral shedding even after lesion removal.
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