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
Choice A rationale:
Urinary output is not directly related to stomatitis, which is inflammation of the mouth and throat. While monitoring urinary output is important in many situations, it is not relevant in this case.
Choice B rationale:
Blood pressure while standing is not directly related to stomatitis either. This assessment is more relevant for conditions such as orthostatic hypotension, which can cause a drop in blood pressure upon standing.
Choice C rationale:
Ability to swallow is crucial in the context of stomatitis. Stomatitis can cause painful sores in the mouth, making it difficult for the client to eat or drink. Assessing the client's ability to swallow will help determine the impact of stomatitis on their nutritional intake and overall well-being.
Choice D rationale:
Frequency of bowel movements is unrelated to stomatitis. This assessment is more relevant for gastrointestinal issues or constipation, not for a condition affecting the mouth and throat.
Correct Answer is B
Explanation
The correct answer isChoice B.
Choice B rationale:
The practical nurse (PN) should instruct the unlicensed assistive personnel (UAP) to keep the client's skin clean and dry. Proper skin care is essential for a client with urinary and fecal incontinence to prevent the development of pressure ulcers. Keeping the skin clean and dry helps reduce moisture-related skin breakdown.
Choice A rationale:
Encouraging the client to rest quietly in bed is not directly related to preventing pressure ulcers. While adequate rest is essential for overall health, it does not specifically address the risk of pressure ulcers in an incontinent client.
Choice C rationale:
Obtaining supplies for contact precautions is unrelated to the client's risk of developing a sacral pressure ulcer. Contact precautions are used to prevent the spread of infectious diseases and do not address skin integrity.
Choice D rationale:
Documenting any changes in skin integrity is important, but it is the responsibility of the healthcare team, including the PN. However, this response does not provide proactive measures to prevent the pressure ulcer from occurring in the first place, which is the primary concern in this situation.
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