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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["C"]
Explanation
The correct answer is choice C. Initiation of changes in infection control measures.
Choice A rationale:
Limiting the client’s fluid intake to avoid hemodilution is not relevant to managing a decreased ANC. Hemodilution is not a concern in this context, and fluid intake should generally be maintained to support overall health.
Choice B rationale:
Avoiding exposure to cold temperatures is not directly related to managing a decreased ANC. While keeping the client comfortable is important, it does not address the increased risk of infection associated with neutropenia.
Choice C rationale:
Initiation of changes in infection control measures is crucial when a client’s ANC decreases. Neutropenia increases the risk of infections, so enhanced infection control practices, such as strict hand hygiene, use of protective isolation, and monitoring for signs of infection, are essential to protect the client.
Choice D rationale:
Increasing the client’s dietary servings of fruits and vegetables is generally beneficial for overall health but does not specifically address the immediate risks associated with a decreased ANC. In fact, certain fresh fruits and vegetables might need to be avoided if they pose a risk of introducing pathogens.
Correct Answer is B
Explanation
Tell the client that the PN will verify that the dispensed medication is the valid prescription. Choice A rationale:
Explaining that the healthcare provider probably prescribed a different medication while the client is hospitalized (Choice A) may create confusion or concern for the client. It is essential to reassure the client and take appropriate action to address the discrepancy in the appearance of the medication.
Choice C rationale:
Explaining that the pharmacy often substitutes generic equivalents for more expensive brands (Choice C) is not applicable in this situation since the client is expressing concern about the appearance of the medication prescribed by the healthcare provider, not a substitution by the pharmacy.
Choice D rationale:
Telling the client that he is probably confused since being hospitalized tends to disorient clients (Choice D) is dismissive of the client's concerns. It is crucial to acknowledge the client's observation and address the issue professionally.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.