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 D

Explanation

Rationale:
A. Advise the adolescent to place the newborn for adoption: Suggesting adoption may be perceived as judgmental and does not address the adolescent’s immediate concern about accessing resources and caring for the baby.

B. Refer the adolescent to a local mental health clinic: While emotional support can be beneficial, referral to mental health services alone does not address practical concerns about affording and caring for the baby. Immediate assistance with resources is a priority.

C. Contact the adolescent's parent for assistance: Confidentiality and the adolescent’s autonomy must be respected unless there is a safety concern. The nurse should not contact parents without the adolescent’s consent.

D. Assist the adolescent in applying for Medicaid: Helping the adolescent apply for Medicaid directly addresses her concerns about affording prenatal care and infant needs. This action provides practical support, empowers her to access healthcare and resources, and promotes positive maternal and fetal outcomes.

A. Perform a vaginal examination every 12 hr. B. Administer betamethasone. C. Provide a low-stimulation environment. D. Maintain bed rest. E. Obtain a 24-hr urine specimen. F. Give antihypertensive medication. G. Monitor intake and output hourly.

Correct Answer is ["B","C","D","E","F","G"]

Explanation

Rationale

A. Perform a vaginal examination every 12 hr: Vaginal examinations should be avoided in a client with severe preeclampsia unless delivery is imminent, as they can stimulate uterine activity and increase the risk of placental abruption. Continuous monitoring and noninvasive assessments are prioritized instead.

B. Administer betamethasone: Betamethasone promotes fetal lung maturity by stimulating surfactant production when preterm delivery before 34 weeks is anticipated. This reduces the risk of neonatal respiratory distress syndrome and intraventricular hemorrhage.

C. Provide a low-stimulation environment: A quiet, dimly lit environment helps minimize CNS stimulation, reducing the risk of seizure activity in clients with severe preeclampsia. Environmental stressors such as bright lights and loud noises should be avoided.

D. Maintain bed rest: Bed rest, particularly in the left lateral position, improves uteroplacental perfusion and reduces blood pressure by minimizing pressure on the vena cava. It also helps limit activity that could elevate BP further.

E. Obtain a 24-hr urine specimen: Collecting a 24-hour urine specimen allows accurate assessment of total protein excretion, which confirms the severity of preeclampsia. Proteinuria greater than 300 mg/24 hr indicates significant renal involvement.

F. Give antihypertensive medication: Antihypertensives such as labetalol or hydralazine help prevent maternal complications like stroke or heart failure from sustained severe hypertension while avoiding excessive BP reduction that could impair uteroplacental blood flow.

G. Monitor intake and output hourly: Close monitoring of intake and output detects early signs of renal compromise or fluid overload, which are common in preeclampsia. Accurate measurement helps guide safe fluid management and prevent pulmonary edema.

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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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Naxlex Comprehensive Predictor Exams

A nurse at a community health clinic is planning care for an adolescent who recently learned that she is pregnant and is concerned about her ability to afford and care for her baby. Which of the following actions should the nurse take?

Correct Answer is D

Explanation

The nurse is continuing to care for the client. Exhibits The nurse is initiating the client's plan of care. Which of the following interventions should the nurse plan to implement? Select all that apply.

Correct Answer is ["B","C","D","E","F","G"]

Explanation

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