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During a home visit, the nurse observes that a client with limited mobility has difficulty accessing the bathroom. What should the nurse do first?
- A. suggest the client installs a bedside commode
- B. assist the client in modifying the home environment
- C. refer the client to an occupational therapist
- D. educate the client on mobility aids
Correct Answer: A
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
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An older female client tells the home health nurse that she has no money, and since she does not deserve to eat, she has not asked anyone to bring her food. What information is most important for a nurse to obtain?
- A. client's thoughts about wanting to hurt herself
- B. medication history for antipsychotic agents
- C. availability of family members to provide meals
- D. community resources to provide financial aid
Correct Answer: A
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
A client with a history of asthma is admitted with shortness of breath. Which finding requires immediate intervention?
- A. Increased respiratory rate.
- B. Absence of breath sounds.
- C. Expiratory wheezes.
- D. Productive cough with green sputum.
Correct Answer: B
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
A client with a history of diabetes mellitus is admitted with hypoglycemia. Which finding requires immediate intervention?
- A. Blood glucose of 60 mg/dL.
- B. Heart rate of 100 beats per minute.
- C. Tremors.
- D. Diaphoresis.
Correct Answer: C
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
A client with a history of chronic obstructive pulmonary disease (COPD) is admitted with pneumonia. Which finding requires immediate intervention?
- A. Oxygen saturation of 88%
- B. Respiratory rate of 24 breaths per minute
- C. Heart rate of 90 beats per minute
- D. Productive cough with green sputum
Correct Answer: D
Rationale: In a client with COPD admitted with pneumonia, a productive cough with green sputum indicates a potential bacterial infection. Green sputum is commonly associated with bacterial pneumonia, which requires immediate intervention with appropriate antibiotics. Monitoring oxygen saturation, respiratory rate, and heart rate are essential in COPD patients, but the presence of green sputum suggests an urgent need for targeted treatment to address the underlying infection. Oxygen saturation of 88% is concerning but may not directly indicate the need for immediate intervention in the absence of other critical symptoms. Respiratory rate of 24 breaths per minute and a heart rate of 90 beats per minute are within normal limits and may not be indicative of an acute issue requiring immediate intervention in this context.
A female client is admitted with a tentative diagnosis of Guillain-Barre syndrome. Which finding is most important for the nurse to report to the healthcare provider?
- A. Facial weakness and difficulty speaking.
- B. Decreased deep tendon reflexes in the legs.
- C. Inability to move the eyes.
- D. Respiratory distress and cyanosis.
Correct Answer: B
Rationale: In Guillain-Barre syndrome, decreased deep tendon reflexes are a critical finding that may indicate impending respiratory failure. This is due to the involvement of the peripheral nervous system affecting the muscles, including those involved in breathing. Reporting decreased deep tendon reflexes promptly is essential to prevent respiratory compromise. Facial weakness, difficulty speaking, and inability to move the eyes are common manifestations of Guillain-Barre syndrome but are not as immediately concerning as respiratory distress and impending respiratory failure.