The nurse observes a client prepare a meal in the kitchen of a rehabilitation facility prior to discharge. What behavior(s) indicate the client understands how to maintain balance safely? Select all that apply.

Bends from the waist to pick trash off the floor.

Leans forward to pull a pan from a high shelf.

Locks knees while preparing food on the counter.

Widens stance while working near the sink.

Brings a heavy can close to body before lifting.

Answer and Explanation

Correct Answer : D,E

A.   Bending from the waist to pick up trash can cause imbalance and strain; it is safer to bend at the knees.

B.   Leaning forward to pull a pan from a high shelf can lead to loss of balance; using a step stool is safer.
C.   Locking the knees can lead to loss of balance and is not a recommended posture.

D. Widening the stance provides a stable base and helps maintain balance while working.
E. Bringing a heavy can close to the body before lifting uses proper body mechanics, reducing the risk of strain and promoting balance.

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Correct Answer is ["A","B","E"]

Explanation

A. This intervention is likely to be ordered due to the patient's fever and elevated heart rate, which may suggest dehydration or the need for increased fluid intake to support hemodynamic stability and mitigate the effects of fever and potential dehydration from fever and nausea.
B. Given the diagnosis of Pneumocystis pneumonia, the patient will likely be on or start antibiotics specific to this infection, such as trimethoprim-sulfamethoxazole. Monitoring for adverse reactions is crucial, especially in a newly diagnosed HIV-positive patient who might be starting multiple new medications.
C. While it is important to monitor CD4 counts in HIV-positive patients to guide treatment decisions, repeating the CD4 count immediately might not be prioritized unless there are specific clinical changes that suggest a rapid decline in immune function. Given the recent test results showing a CD4 count of 443 cells/mm^3, immediate retesting might not be clinically justified unless guided by other symptoms or considerations not detailed here.
D. Pneumocystis pneumonia does not require airborne isolation as it is not typically contagious between people under normal circumstances. Instead, it arises as an opportunistic infection in individuals with weakened immune systems. Hence, this order would not be appropriate unless there were other infections suspected that require such precautions.
E. The patient reports severe nausea, which not only is distressing but can also prevent the patient from taking oral medications and maintain necessary nutrition. Administering an antiemetic can help manage this symptom effectively.

A. Do not take diabetes medication when feeling sick. B. Have some form of rapid acting glucose easily accessible. C. Obtain an A1C blood test every year to monitor glucose control. D. Using salt, herbs, and spices will improve the flavor of foods.

Correct Answer is B

Explanation

A. Not taking diabetes medication when feeling sick could lead to uncontrolled blood sugar levels.
B. Having rapid-acting glucose readily available indicates understanding of the importance of managing hypoglycemic episodes.
C. While important, obtaining an A1C test annually is not directly related to managing acute hyperglycemia.
D. Using salt, herbs, and spices does not directly address blood glucose control.

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The nurse observes a client prepare a meal in the kitchen of a rehabilitation facility prior to discharge. What behavior(s) indicate the client understands how to maintain balance safely? Select all that apply.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Patient Data Exhibits What order(s) should the nurse anticipate being prescribed after an update is reported to the healthcare providers? Select all that apply.

Correct Answer is ["A","B","E"]

Explanation

The nurse is providing teaching to a client admitted with a blood glucose level of 580 mg/dL (32.2 mmol/L) about preventing complications related to diabetes mellitus. Which statement by the client indicates understanding? Reference Range: Glucose [74 to 106 mg/dL (4.1 to 5.9 mmol/L)]

Correct Answer is B

Explanation

Following a fractured left tibia, which necessitated placement of long leg cast, a client is using crutches to ambulate. During an orthopedic follow-up visit, a client reports to the nurse having difficulty managing the crutches. Which assessment should the nurse perform?

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Exhibits Nursing actions: Indicated/contraindicated/non-urgent

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