The home health nurse is reviewing the personal care needs of an older adult client who lives alone. What client assessment finding(s) indicate(s) the need to assign an unlicensed assistive personnel (UAP) to provide routine foot care and has the client's toenails? Select all that apply.
Shufling gait.
Urinary incontinence.
Syncope when bending.
Hand tremors.
Correct Answer : A,C,D
The correct answer is Choice A, Choice C, and Choice D.
Choice A rationale: A shuffling gait can indicate mobility issues, making it difficult for the client to safely perform foot care and toenail clipping. This increases the risk of falls and injuries.
Choice B rationale: Urinary incontinence does not directly affect the ability to perform foot care or toenail clipping. It is more related to bladder control issues.
Choice C rationale: Syncope when bending suggests that the client may experience dizziness or fainting when bending over, making it unsafe for them to perform foot care and toenail clipping.
Choice D rationale: Hand tremors can make it challenging for the client to handle nail clippers or other tools needed for foot care, increasing the risk of injury.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason: Skin turgor is a method to assess hydration status, but it is not the most accurate indicator of fluid balance in a patient with fluid volume overload.
Choice B reason: Monitoring weight is the most accurate method to assess fluid balance. A sudden increase or decrease in weight is indicative of fluid changes.
Choice C reason: Blood pressure can be affected by fluid volume changes, but it does not provide a direct measure of fluid balance.
Choice D reason: Lung sounds can indicate fluid overload in the lungs but do not give a complete picture of overall fluid balance.
Correct Answer is C
Explanation
Choice A reason: This response is inappropriate and dismissive of the sibling's concern and the client's need for communication assistance.
Choice B reason: Providing medical information to someone who is not an approved interpreter could breach confidentiality and privacy regulations.
Choice C reason: It is important to use an approved interpreter to ensure accurate and confidential communication of medical information.
Choice D reason: While the healthcare provider will share information, it is essential to use an approved interpreter to facilitate understanding and maintain confidentiality.
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