A nurse is caring for a client who is being discharged home following a total hip arthroplasty. Which of the following findings in the home should the nurse Identify as a potential risk for Injury?
Elevated toilet seats
No stairs in the home
Reclining chair with a straight back
Large soaking tub without a shower head
The Correct Answer is D
A: Elevated toilet seats are often recommended following hip surgery to reduce strain, not increase the risk of injury.
B: No stairs in the home is generally a positive feature for a client following hip surgery, reducing fall risk.
C: A reclining chair with a straight back may provide comfortable seating without increasing the risk of injury.
D: A large soaking tub without a shower head can increase the risk of falls and injury due to difficulty getting in and out of the tub, especially for a client recovering from hip surgery.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
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Correct Answer is []
Explanation
Based on the provided nurses' notes, the client exhibits symptoms that may suggest a brief psychotic disorder, characterized by delusions, hallucinations, disorganized speech, or grossly disorganized or catatonic behavior. The client's history of similar episodes and family history could support this diagnosis. To assess the client's progress, the nurse should monitor the client's ability to care for themselves and assess any suicide risk due to the client's recent stressors and emotional state. Actions that could be beneficial include reducing external stimuli to prevent sensory overload and engaging with the client several times each day to establish trust, which can help alleviate anxiety and foster a therapeutic environment.
Correct Answer is D
Explanation
A: Changing the TPN bag and tubing every 24 hours is standard practice to prevent infection, so this action is appropriate.
B: Checking glucose levels every 6 hours is necessary because TPN can significantly affect blood glucose levels.
C: Gradually increasing the TPN rate is a standard procedure to monitor tolerance to the infusion.
D: This indicates a need for intervention. TPN lines should not be used for any other infusions to prevent contamination and interactions between the nutrition formula and medications.
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