A nurse is providing discharge teaching about safety considerations to an older adult client who lives at home. The client has heart failure and a new prescription for hydrochlorothiazide. Which of the following statements by the client indicates an understanding of the teaching?
"I will weigh myself once weekly."
"I will take my new medication in the evening."
"I will take a hot bath before going to bed."
"I will leave a light on in my bathroom at night."
The Correct Answer is D
A. "I will weigh myself once weekly." Clients with heart failure should weigh themselves daily to monitor for fluid retention. A sudden weight gain (e.g., 2-3 lbs in 24 hours or 5 lbs in a week) may indicate worsening heart failure and should be reported to the provider.
B. "I will take my new medication in the evening." Hydrochlorothiazide is a diuretic that increases urine output. Taking it in the evening can lead to nocturia and sleep disturbances. Instead, it should be taken in the morning to minimize nighttime urination.
C. "I will take a hot bath before going to bed." Hot baths can cause vasodilation, leading to a drop in blood pressure (orthostatic hypotension), which increases the risk of dizziness and falls, especially in older adults taking diuretics. A warm (not hot) bath is safer.
D. "I will leave a light on in my bathroom at night." Older adults, especially those taking diuretics like hydrochlorothiazide, are at increased risk for nocturia and falls due to frequent trips to the bathroom. Keeping a light on in the bathroom at night enhances visibility and reduces the risk of falls, which is a major concern in this population.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. "Tell me more about your partner." - While exploring the client's feelings about their partner may be relevant to understanding their current emotional state, it does not directly address the statement indicating suicidal ideation. The priority in this situation is to assess the client's risk of self-harm or suicide.
B. "Have you thought about harming yourself?"
This response directly addresses the client's statement expressing thoughts of dying and allows the nurse to assess the client's risk of self-harm or suicide. It opens up a dialogue about the client's feelings and intentions, which is crucial for ensuring their safety and providing appropriate support and intervention.
C. "You should discuss these feelings with your provider." - While encouraging the client to communicate with their healthcare provider is important, it does not address the immediate concern of potential self-harm or suicide. The nurse should assess the client's safety and provide support before encouraging further discussion with the provider.
D. "Why did you stop taking your medication?" - While medication non-adherence may contribute to worsening symptoms of depression, it is not the immediate concern in this situation. The client's statement expressing thoughts of dying requires immediate assessment of suicidal ideation and intervention to ensure their safety.
Correct Answer is D
Explanation
A. Administer metronidazole:
Metronidazole is an antibiotic medication used to treat bacterial infections, particularly those caused by anaerobic bacteria and certain parasites. It is not effective against viral infections like influenza. Administering metronidazole would not prevent the spread of influenza.
B. Don protective eyewear before entering the room:
Protective eyewear is typically worn when there is a risk of exposure to bodily fluids or other potentially infectious materials that could splash or splatter into the eyes. While protective eyewear is an important infection control measure in certain situations, it is not specifically indicated for preventing the spread of influenza, which primarily spreads through respiratory droplets.
C. Place the client in a negative airflow room:
Negative airflow rooms are designed to prevent airborne transmission of infectious agents by maintaining negative air pressure, which prevents contaminated air from flowing out of the room and into adjacent areas. While negative airflow rooms may be used for certain infectious diseases, such as tuberculosis, they are not typically indicated for influenza, which primarily spreads through respiratory droplets. Moreover, negative airflow rooms are often limited in availability and may not be necessary for every client with influenza.
D. Wear a mask when working within 3 feet of the client.
Influenza is primarily spread through respiratory droplets when an infected person coughs, sneezes, or talks. Wearing a mask when working within close proximity (within 3 feet) of the client helps prevent the nurse from inhaling respiratory droplets containing the influenza virus, reducing the risk of transmission. Masks act as a barrier that helps trap respiratory secretions and prevent them from reaching the nurse's mouth and nose.
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