Nokea
A healthcare professional is preparing to transfer a client who can bear weight on one leg from the bed to a chair. After securing a safe environment, which of the following actions should the healthcare professional take next?
- A. Assess the client for orthostatic hypotension
- B. Obtain a gait belt
- C. Ensure the client has proper footwear
- D. Ask the client to perform range-of-motion exercises
Correct Answer: A
Rationale: Assessing the client for orthostatic hypotension is the priority before transferring a client who can bear weight on one leg. This assessment helps identify the risk of dizziness or fainting when the client moves from a supine to an upright position. Obtaining a gait belt may be necessary for the transfer, but assessing for orthostatic hypotension comes first to ensure the safety of the client. Ensuring the client has proper footwear is important for preventing falls during ambulation but is not the immediate next step in this situation. Asking the client to perform range-of-motion exercises is not necessary before the transfer and does not address the immediate safety concern of orthostatic hypotension.
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A client with a fractured femur has a BP of 140/94 mmHg and denies any history of HTN. Which of the following actions should the nurse take first?
- A. Request a prescription for an antihypertensive medication.
- B. Ask the client if they are having pain.
- C. Request a prescription for an antianxiety medication.
- D. Return in 30 minutes to recheck the client's BP.
Correct Answer: B
Rationale: The correct action is to ask the client if they are having pain. Pain can lead to temporary increases in blood pressure. Addressing pain as a potential cause is the initial step before considering medication adjustments. Requesting an antihypertensive medication or an antianxiety medication without assessing pain first would not address the immediate concern. Returning to recheck the BP can be done after addressing the potential pain issue.
While ambulating an unsteady client who begins to fall, which of the following actions should the nurse take?
- A. Allow the client to slide down their outstretched leg.
- B. Place their arms around the client to prevent the fall.
- C. Remain upright as the client falls toward them.
- D. Move quickly to a position in front of the client.
Correct Answer: A
Rationale: When a client is falling, allowing them to slide down your leg can help control the descent and prevent injury. This technique ensures a more controlled fall compared to attempting to catch or stop the client abruptly, which could lead to both the client and the nurse getting injured. Placing arms around the client may not provide enough support or control during the fall. Remaining upright or moving quickly in front of the client might not be practical or safe in this scenario.
The caregiver is assessing an 8-month-old child with atonic cerebral palsy. Which statement from the caregiver supports the presence of this problem?
- A. When I place my finger in the left hand, the baby does not respond with a grasp.
- B. My baby does not seem to track objects when I move toys in front of their face.
- C. When it thundered loudly last night, the baby did not even startle.
- D. When I place the baby in a supine position, that's how I find the baby.
Correct Answer: D
Rationale: The statement 'When I place the baby in a supine position, that's how I find the baby' supports the presence of atonic cerebral palsy. In this type of cerebral palsy, the child may have poor muscle tone, making it difficult for them to roll from a back-lying position. This inability to roll indicates a lack of muscle tone, which is a characteristic feature of atonic cerebral palsy. Choices A, B, and C do not directly relate to the muscle tone issues typical of atonic cerebral palsy. Choice A focuses on a lack of grasp response, which may suggest motor issues but not specifically atonic cerebral palsy. Choice B refers to visual tracking, and choice C is about the startle reflex, neither of which are defining characteristics of atonic cerebral palsy.
When providing hygiene for an older-adult patient, why does the nurse closely assess the skin?
- A. Outer skin layer becomes less resilient.
- B. Less frequent bathing may be required.
- C. Skin becomes more subject to bruising.
- D. Sweat glands become less active.
Correct Answer: B
Rationale: The correct answer is B: 'Less frequent bathing may be required.' In older adults, daily bathing or using hot water and harsh soap can lead to excessively dry skin. Therefore, the nurse closely assesses the skin to determine if less frequent bathing is necessary to prevent skin dryness and maintain skin integrity. Choice A is incorrect because the outer skin layer does not become less resilient with age. Choice C is incorrect as aging skin is actually more prone to bruising due to thinning of the skin. Choice D is incorrect because sweat gland activity generally decreases with age, leading to reduced skin moisture rather than increased activity.
A community health nurse is preparing a campaign about seasonal influenza. Which of the following plans should the nurse include as a secondary prevention?
- A. Screening groups of older adults in nursing care facilities for early influenza manifestations
- B. Promoting hand hygiene to prevent the spread of influenza
- C. Administering influenza vaccinations
- D. Educating about the importance of healthy lifestyle choices to prevent influenza
Correct Answer: A
Rationale: The correct answer is A. Secondary prevention aims to detect and address health issues early. Screening older adults in nursing care facilities for early influenza manifestations is an example of secondary prevention by identifying cases at an early stage. Choice B, promoting hand hygiene, is a form of primary prevention that aims to prevent the occurrence of influenza. Choice C, administering influenza vaccinations, is a form of primary prevention as well, focusing on preventing the disease before it occurs. Choice D, educating about healthy lifestyle choices, is more related to health promotion and primary prevention rather than secondary prevention.