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A home health nurse is assessing an older adult client in the home who has decreased vision due to a history of glaucoma. Which of the following findings should the nurse identify as a safety risk?
- A. Scatter rugs are present in the kitchen,
- B. Handrails are present in the bathroom.
- C. Electrical cords are placed along the walls.
- D. Uses a microwave for cooking.
Correct Answer: A
Rationale: Scatter rugs can cause tripping and slipping, posing a significant fall risk for someone with vision impairment. Handrails provide support and help prevent falls, making them a safety feature, not a risk. Electrical cords placed along walls reduce tripping hazards. A microwave is generally safer than a stove, reducing the risk of burns and fires.
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A nurse is admitting a client who has sustained severe burn injuries in a grease fire. The nurse shades in a diagram indicating the burned surface areas. Using the Rule of Nines, the nurse should estimate that the client has burned what percentage of body surface area? (Round the answer to the nearest tenth. Use a leading zero if it applies. Do not use a trailing zero.)
Correct Answer: 31.5
Rationale: Using the Rule of Nines, the anterior trunk is 18%, each upper limb (upper arm) is 4.5%, and each forearm is 2.25%. The calculation yields 24.75% for anterior and 6.75% for posterior, totaling 31.5% of body surface area burned.
A nurse is providing teaching to a client about preventing skin cancer. Which of the following client statements indicates a need for further teaching?
- A. Eating a high fiber diet will reduce my risk for developing skin cancer
- B. should check my skin monthly for any changes.
- C. should use sunscreen even on cloudy days.
- D. should avoid the use of tanning booths.
Correct Answer: A
Rationale: There is no evidence that a high-fiber diet reduces skin cancer risk, indicating a misunderstanding. Other statements reflect correct preventive measures.
A nurse is teaching a group of clients about lifestyle modifications that could decrease risk factors for developing hearing loss. Which of the following risk factors should the nurse include in the teaching?
- A. Consume foods high in potassium
- B. Avoid smoking tobacco products
- C. increase oral intake of water
- D. Limit alcohol to two drinks daily
Correct Answer: B
Rationale: Smoking impairs blood flow to the cochlea and auditory nerve, increasing hearing loss risk. Potassium, hydration, and moderate alcohol are not directly linked to hearing loss prevention.
A nurse is providing teaching to a client about preventing skin cancer. Which of the following client statements indicates a need for further teaching?
- A. Eating a high fiber diet will reduce my risk for developing skin cancer
- B. should check my skin monthly for any changes.
- C. should use sunscreen even on cloudy days.
- D. should avoid the use of tanning booths.
Correct Answer: A
Rationale: There is no evidence that a high-fiber diet reduces skin cancer risk, indicating a misunderstanding. Other statements reflect correct preventive measures.
A nurse is assessing a client who has fluid overload. Which of the following findings should the nurse expect? (Select all that apply.)
- A. increased heart rate
- B. Increase hematocrit
- C. increased blood pressure
- D. Increased temperature
- E. increased respiratory rate
Correct Answer: A,C,E
Rationale: Tachycardia occurs as the heart compensates for increased blood volume. Hypertension results from increased vascular resistance due to excess fluid. Increased respiratory rate is due to pulmonary congestion from fluid overload. Hematocrit decreases due to dilution, and temperature is not directly affected.