A home health nurse is planning care for an older adult client who has vision loss and takes medications throughout the day.
Which of the following actions should the nurse include in the plan?

Cover appliance cords with throw rugs.

Visit the client once per month to assess medication usage.

Use container lids of different shapes to indicate times of administration.

Rearrange furniture to clear walkways.

Answer and Explanation

The Correct Answer is C

Choice A rationale:

Covering appliance cords with throw rugs is not an appropriate action to address the needs of a client with vision loss and medication management. While it promotes safety by reducing tripping hazards, it does not directly address the client's medication administration needs. Implementing measures that specifically assist the client in managing medications safely is essential in this scenario.

Choice B rationale:

Visiting the client once per month to assess medication usage is insufficient for an older adult with vision loss who takes medications throughout the day. Regular and more frequent assessments are necessary to ensure the client's safety and adherence to the medication regimen. The nurse should consider more proactive measures to support the client, such as providing medication organizers or arranging for a home healthcare aide to assist with medication administration daily.

Choice C rationale:

This is the correct answer. Using container lids of different shapes to indicate times of administration is an effective strategy for clients with vision loss. Associating specific shapes with different times of the day helps the client differentiate between medications, promoting accurate dosing. This method is tactile and easy for the client to understand, enhancing their ability to manage medications independently and safely.

Choice D rationale:

Rearranging furniture to clear walkways is a general safety measure but does not specifically address the client's medication administration needs. While it can prevent falls and accidents, it does not facilitate the client's ability to distinguish between different medications or their dosing schedules. The focus should be on implementing strategies that directly support the client in managing their medications effectively despite their visual impairment.

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Correct Answer is C

Explanation

Choice A rationale:

Allergic transfusion reactions are characterized by symptoms such as hives, itching, and shortness of breath. While allergic reactions can cause discomfort, they do not typically present with the symptoms described in the scenario, such as chills, headache, low-back pain, and chest tightness.

Choice B rationale:

Febrile nonhemolytic transfusion reactions are characterized by fever and chills, but they do not usually cause headache, low-back pain, or chest tightness. These reactions occur due to antibodies against donor leukocytes or platelets.

Choice C rationale:

Acute hemolytic transfusion reactions occur when there is a mismatch in blood type between the donor and recipient, leading to rapid destruction of transfused red blood cells. This reaction can cause symptoms such as chills, fever, low-back pain, chest tightness, and hemoglobinuria (presence of hemoglobin in the urine) It is a medical emergency that requires immediate cessation of the transfusion, supportive care, and treatment for potential complications such as acute kidney injury.

Choice D rationale:

Bacterial transfusion reactions occur due to bacterial contamination of the blood product. These reactions can cause symptoms such as fever, chills, hypotension, and shock. While bacterial transfusion reactions can be serious, the symptoms described in the scenario, including headache and low-back pain, are not typically associated with this type of reaction.

A. "Why are you interested in seeing your therapist's notes?" B. "I don't think you will benefit from reviewing your therapist's notes right now." C. "We can provide a copy of your records, but the therapist's notes are not included." D. "Are you not happy with your treatment?"

Correct Answer is C

Explanation

A. Incorrect. While the nurse is curious about the client's reasons, it may come across as intrusive or defensive.
B. Incorrect. Making an assumption about the client's potential benefit is not appropriate. The client has the right to access their own records.
C. Correct. This response is respectful of the client's request while also explaining the limitation related to therapist notes.
D. Incorrect. The about the client's happiness with treatment is not directly related to their request for therapist notes.

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A home health nurse is planning care for an older adult client who has vision loss and takes medications throughout the day.Which of the following actions should the nurse include in the plan?

Nursing Test Bank

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Correct Answer is C

Explanation

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A home health nurse is planning care for an older adult client who has vision loss and takes medications throughout the day.
Which of the following actions should the nurse include in the plan?