A nurse is speaking with several clients at a health fair. Which of the following statements should the nurse assess further?
"I have to change my hearing aid battery weekly."
"I have to turn my head completely to see things that are beside me."
"I prepare my medications for the week on Sundays."
"I prepare all of my own meals."
The Correct Answer is B
The correct answer is Choice B because, "I have to turn my head completely to see things that are beside me." This statement suggests the possibility of impaired peripheral vision, which could be a safety concern. The nurse should assess further and possibly refer the client for further evaluation.
Choice A is wrong because, "I have to change my hearing aid battery weekly," is not the correct answer as it is a routine self-care task for individuals with hearing aids. Choice C is wrong because, "I prepare my medications for the week on Sundays," is not the correct answer as it is a routine self-care task for individuals who take multiple medications. Choice D is wrong because, "I prepare all of my own meals," is not the correct answer as it is a routine selfcare task for many individuals.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
The correct answer is Choice D because, "Household contacts will receive prophylactic antibiotics." The nurse should include in the teaching that household contacts of the child with pertussis will receive prophylactic antibiotics to prevent the spread of the disease. This answer is correct because pertussis is a highly contagious respiratory illness that spreads through respiratory droplets, and prophylactic antibiotics can help prevent the spread of the disease.
Choice A is wrong because is incorrect because a dehumidifier will not prevent the spread of pertussis.
Choice B is wrong because is incorrect because pertussis does not cause a rash.
Choice C is wrong because is incorrect because herd immunity occurs when a large percentage of the population is immunized against a disease, and pertussis is preventable with vaccination.
Correct Answer is B
Explanation
Choice B is correctbecause: Understanding the client's perspective on their living situation will help the nurse determine whether the client is aware of risks (such as unsafe living conditions or being at risk of harm) and if they need immediate interventions, like a safe place to stay or healthcare.
Developing client teaching using a variety of strategies (Choice A is wrong because) may be important for the client's long-term success, but it is not the priority at this time. While securing shelter is essential, the first step is to determine if the client recognizes their need for shelter, and whether they are ready or able to develop those goals themselves. Discussing the risks of being homeless with the client (Choice D is wrong because) can be done once the client's immediate need for shelter is met.
Choice A is wrong because: Developing client teaching using a variety of strategies is not the first priority in this situation.
Choice B is wrong because: Determining the client's understanding of her living situation is not the first priority in this situation.
Choice D is wrong because: Discussing the risks of being homeless with the client is not the first priority in this situation.
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