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.
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Related Questions
Correct Answer is ["B","C","D","G","H"]
Explanation
A. Contact precautions are not indicated based on the assessment findings provided. Preeclampsia is primarily a hypertensive disorder of pregnancy characterized by systemic manifestations such as elevated blood pressure, proteinuria, and multiorgan involvement. It is not transmitted through direct contact, so contact precautions are unnecessary.
B. The client is exhibiting signs and symptoms consistent with preeclampsia, including right upper abdominal pain, headache, nausea, vomiting, facial edema, weight gain, and elevated blood pressure. Monitoring urinary output is essential for assessing renal function and detecting oliguria, which is a potential complication of preeclampsia.
C. Reducing stimuli, such as bright lights and loud noises, can lower the risk of seizures in clients with preeclampsia.
D. The client's blood pressure readings are elevated, indicating hypertension, which is a hallmark sign of preeclampsia. Monitoring blood pressure regularly is crucial for assessing the severity of hypertension and guiding management.
E. Amniocentesis is not indicated based on the assessment findings provided. Amniocentesis is a diagnostic procedure typically performed to obtain amniotic fluid for various purposes, such as fetal lung maturity assessment or genetic testing. In the context of preeclampsia, it is not a standard intervention.
F. Internal fetal monitoring is typically used during labor to provide a more accurate reading of the baby's heart rate. It involves guiding a thin wire through the cervix and attaching it to the baby's scalp. At 30 weeks gestation, internal monitoring would not be standard practice as it is invasive and labor has not yet commenced.
G. Deep tendon reflexes (DTRs) are assessed to monitor for signs of neurological involvement in preeclampsia. Hyperreflexia, as indicated by a 3+ DTR bilaterally, is a characteristic finding in severe preeclampsia and may indicate central nervous system irritability.
H. Bed rest is often recommended for clients with preeclampsia to reduce physical activity and minimize the risk of complications such as eclampsia or stroke. It can help lower blood pressure and reduce the risk of placental abruption.
Correct Answer is D
Explanation
A. This would involve irregular beats and potentially a visible compensatory pause, not a prolonged PR interval.
B. Atrial fibrillation features an irregularly irregular rhythm and no discernible PR intervals.
C. Defined by a heart rate less than 60/min with a normal rhythm and electrical pattern, which does not apply here given the normal rate and prolonged PR interval.
D. A first-degree atrioventricular (AV) block is characterized by a prolonged PR interval (greater than 0.20 seconds) in the presence of a normal heart rate and rhythm, which aligns with the client’s PR interval of 0.24 seconds and a heart rate of 69/min
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