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A nurse is determining if a homebound client is eligible for Meals-on-Wheels. Which of the following is the most important factor for the nurse to consider?
- A. The client's level of family support
- B. The client's financial resources
- C. The client's access to transportation
- D. The client's ability to prepare meals
Correct Answer: D
Rationale: The correct answer is D: The client's ability to prepare meals. This is crucial as Meals-on-Wheels provides food delivery for those unable to cook. By assessing the client's meal preparation ability, the nurse can determine if the service is necessary. Choice A may be helpful, but not as critical as the client's own ability. Choice B is important but not the most crucial for Meals-on-Wheels eligibility. Choice C is relevant, but if the client cannot prepare meals, transportation to get food is secondary.
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A rehabilitation nurse is developing an activity plan for a client. The nurse should recognize that which activity plan would best conserve the client's energy without compromising physical or mental health?
- A. Restricting visitors to a few hours in the afternoon to promote client rest
- B. Scheduling all activities within a small block of time to allow the client a longer, uninterrupted rest period
- C. Scheduling toilet breaks before and after any other planned activity
- D. Scheduling energy-intensive activities at the time of day when the client has higher energy levels
Correct Answer: D
Rationale: The correct answer is D: Scheduling energy-intensive activities at the time of day when the client has higher energy levels. This option best conserves the client's energy as it aligns the demanding tasks with the client's peak energy periods, optimizing efficiency and reducing fatigue. This approach ensures that the client can complete tasks requiring more physical or mental effort when they are most capable, minimizing strain and preventing energy depletion. Restricting visitors (A) may not necessarily conserve energy as social interactions can be energizing for some clients. Scheduling all activities within a small block of time (B) may lead to fatigue if demanding tasks are clustered together. Scheduling toilet breaks before and after activities (C) is important but does not address energy conservation directly.
The nurse is preparing for an initial home care visit for a client with diabetes. Which action by the nurse is appropriate? SELECT ALL THAT APPLY
- A. Going automatically into the client's bedroom
- B. Thanking the client for arranging a home visit
- C. Arranging mutual future visits
- D. Asking how they are managing at home
- E. Sitting down and discussing with the client and family members
Correct Answer: C,D,E
Rationale: The correct actions (C, D, E) are appropriate for the initial home care visit for a client with diabetes. C is correct because arranging mutual future visits establishes continuity of care. D is correct since asking about home management helps assess the client's self-care abilities. E is essential as it promotes open communication and involvement of the client and family in the care plan. A is incorrect as entering the client's bedroom without permission violates privacy. B is incorrect as it is general politeness and not specific to diabetes care.
The nurse is performing the Romberg test on a client during a neurological assessment. Which of the following best describes the rationale for conducting the Romberg test?
- A. To measure respiratory rate and depth
- B. To evaluate coordination and fine motor skills
- C. To test for proprioception and vestibular function
- D. To assess cranial nerve function related to facial expression
Correct Answer: C
Rationale: The Romberg test is performed to assess the client's ability to maintain balance with eyes closed, testing proprioception and vestibular function. Proprioception is the sense of body position, while vestibular function relates to balance and spatial orientation. This test helps to identify sensory ataxia, where proprioceptive input is impaired. By eliminating visual input, the Romberg test challenges the vestibular and proprioceptive systems to maintain balance. Choices A, B, and D are incorrect as they do not relate to the specific purpose of the Romberg test in assessing proprioception and vestibular function.
A nurse is assessing a client who reports a severe headache and stiff neck. The nurse's assessment reveals positive Kernig's and Brudzinski's signs. Which of the following actions should the nurse perform first?
- A. Decrease bright lights
- B. Implement droplet precautions
- C. Initiate IV access
- D. Administer antibiotics
Correct Answer: B
Rationale: The correct answer is B: Implement droplet precautions. This is the first action the nurse should take because positive Kernig's and Brudzinski's signs suggest the client may have meningitis, which is highly contagious through respiratory droplets. Implementing droplet precautions will help prevent the spread of the infection to others. Decreasing bright lights (A) may be helpful for the client's comfort but is not the priority. Initiating IV access (C) and administering antibiotics (D) are important interventions but should be done after implementing precautions to prevent transmission of the infection.
A nurse is teaching the family of a client who has a new diagnosis of epilepsy about actions to take if the client experiences a seizure. Which of the following instructions should the nurse include in the teaching?
- A. Insert a padded tongue blade into the client's mouth
- B. Restrain the client
- C. Move objects away from the client
- D. Place the client on his back
Correct Answer: C
Rationale: The correct answer is C: Move objects away from the client. This instruction is crucial to prevent injury during a seizure by creating a safe environment. Placing objects away from the client reduces the risk of them hitting or injuring themselves. It also allows for a clear space for the client's movements during the seizure.
Choice A is incorrect as inserting a padded tongue blade can cause injury and obstruct the client's airway. Choice B is incorrect as restraining the client can lead to further injury and is not recommended during a seizure. Choice D is incorrect as placing the client on their back can increase the risk of choking or aspiration if they vomit during the seizure.