During a home visit, the home health practical nurse (PN) observes an older client attempting to ambulate to the bathroom and notes that the client is unsteady and holds on to furniture while refusing any assistance. Which action should the PN implement?

Determine home navigational safety hazards.

Encourage the client to obtain a medical alert device.

Recommend that the client obtain a walker.

Maintain the client's privacy while in the bathroom.

Answer and Explanation

The Correct Answer is A

The correct answer is Choice A:

"Determine home navigational safety hazards.”. Choice A rationale:

The PN should first assess the client's home for safety hazards that may be contributing to the client's unsteadiness and increased fall risk. Identifying and addressing these hazards can help create a safer environment for the client and potentially prevent accidents.

Choice B rationale:

Encouraging the client to obtain a medical alert device is not the immediate priority in this situation. Addressing the client's safety and identifying potential hazards should be the first step before considering additional measures like medical alert devices.

Choice C rationale:

Recommending that the client obtain a walker is premature without first assessing the home

environment and determining if there are any correctable safety issues. The PN should prioritize safety assessment before recommending any assistive devices.

Choice D rationale:

While maintaining the client's privacy is important, it is not the most urgent action in this scenario. The priority is to assess the client's safety and identify potential hazards in the home. Privacy concerns can be addressed afterward.

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Correct Answer is B

Explanation

The correct answer is choice B: Culture for sensitive organisms.

Choice A rationale:
C-reactive protein level - C-reactive protein (CRP) is a blood test marker for inflammation in the body. While it could indicate an infection, it is not specific enough to identify the type of infection or the causative organism.
Choice B rationale:
Culture for sensitive organisms - When a wound has a moderate amount of yellow and green drainage and a foul odor, it is often a sign of a bacterial infection. A culture for sensitive organisms can help identify the specific bacteria causing the infection, which is crucial for determining the most effective treatment.
Choice C rationale:
Serum albumin - Serum albumin levels can indicate a person’s nutritional status. Low levels can slow wound healing, but they do not directly indicate the presence of an infection.
Choice D rationale:
Serum blood glucose (BG) level - High blood glucose levels can impair the immune response and slow wound healing, making a person more susceptible to infections. However, like CRP, it does not provide information about the specific organism causing the infection.

A. Consult with the charge nurse about implementing suicide precautions. B. Sit quietly in the client's room until the client is ready to verbalize his feelings. C. Leave the room after offering to return to the client's room at a later time. D. Notify a member of the client's family of the need to come to stay with the client.

Correct Answer is C

Explanation

The correct answer is choice C: Leave the room after offering to return to the client's room at a later time.

Choice A rationale:

Consulting with the charge nurse about implementing suicide precautions is not appropriate in this situation. The client has not expressed suicidal ideation or intent, and such an action could be invasive and distressing for the client.

Choice B rationale:

Sitting quietly in the client's room until the client is ready to verbalize his feelings might seem supportive, but it disregards the client's request for alone time. It's essential to respect the client's wishes and provide an opportunity for self-reflection and privacy.

Choice C rationale:

Leaving the room after offering to return to the client's room at a later time is the most appropriate action. The client has requested solitude, and respecting his autonomy is crucial in building trust and rapport.

Choice D rationale:

Notifying a member of the client's family of the need to come stay with the client is not necessary at this point. The client's desire for alone time does not indicate an immediate need for family support. The practical nurse should first respect the client's request and give him space to process the news. If the client later expresses a need for family support, appropriate actions can be taken accordingly.

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During a home visit, the home health practical nurse (PN) observes an older client attempting to ambulate to the bathroom and notes that the client is unsteady and holds on to furniture while refusing any assistance. Which action should the PN implement?

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Naxlex Comprehensive Predictor Exams

Correct Answer is B

Explanation

A male client who has just been told he has cancer asks the practical nurse (PN) to leave his room so he can be alone. Which action should the PN implement?

Correct Answer is C

Explanation

The practical nurse (PN) learns that a client who is receiving chemotherapy has developed stomatitis. Which information should the PN obtain from the client during a focused assessment?

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