Nokea
The home health nurse has made a visit to an 85-year-old female client's home who has recently had surgery to replace her left knee. The client has been discharged from a rehab facility and has been able to walk on her own. The nurse assesses the need for teaching related to fall prevention. What should the nurse include in this teaching plan?
- A. The client should remove all scatter rugs from the floor and minimize clutter.
- B. The client should not limit her movement within the home unless advised by the physician.
- C. The client should have a raised toilet seat and grab bars available in the bathroom.
- D. The client should not wear a robe and socks while walking in the house.
Correct Answer: A
Rationale: The correct answer is to instruct the client to remove all scatter rugs from the floor and minimize clutter. Rugs and clutter are common causes of falls in the home, especially for the elderly or those with gait issues. Removing them can significantly reduce the risk of falls. While having a raised toilet seat and grab bars in the bathroom is important for safety, it is not the priority in this scenario. The client should not limit her movement within the home unless specifically advised by the physician, as maintaining mobility is essential for recovery. Lastly, the client should avoid wearing robes and socks while walking in the house to prevent tripping, slipping, or falling on slippery floors.
You may also like to solve these questions
Which of the following is most likely to impact the body image of an infant newly diagnosed with Hemophilia?
- A. immobility
- B. altered growth and development
- C. hemarthrosis
- D. altered family processes
Correct Answer: D
Rationale: Altered Family Processes is a significant factor that can impact the body image of an infant newly diagnosed with Hemophilia. Infants are highly sensitive to the reactions of their caregivers, and a new diagnosis like Hemophilia can introduce stress and uncertainties into the family dynamics. This can affect the infant's sense of security, trust development, and how they perceive themselves. Immobility, while a potential long-term effect of Hemophilia, is not the immediate impact on body image for a newly diagnosed infant. Altered growth and development would take time to manifest and would not be an immediate concern after a recent diagnosis. Hemarthrosis, although a characteristic symptom of Hemophilia, is a physical manifestation rather than a direct influence on body image perception in a newly diagnosed infant.
An assessment of the skull of a normal 10-month-old baby should identify which of the following?
- A. closure of the posterior fontanel.
- B. closure of the anterior fontanel.
- C. overlap of cranial bones.
- D. ossification of the sutures.
Correct Answer: B
Rationale: The correct answer is the closure of the anterior fontanel. By 10 months of age, the anterior fontanel should be closed. The posterior fontanel should actually close by the age of 2 months, making choice A incorrect. Overlap of cranial bones is not a typical finding in a normal 10-month-old baby's skull, so choice C is incorrect. Ossification of the sutures is an ongoing process in skull development and should not be a definitive indicator at this age, making choice D incorrect.
What is the primary theory that explains a family's concept of health and illness?
- A. Health Belief Model
- B. Education Factor
- C. Family Health Belief Model
- D. Family Dynamics Model
Correct Answer: A
Rationale: The correct answer is the Health Belief Model. The Health Belief Model is a widely recognized theory that explains individuals' perceptions and behaviors related to health and illness. It considers factors such as perceived susceptibility, severity of health issues, benefits of action, and barriers to taking action. Choices B, C, and D are incorrect. Choice B, 'Education Factor,' is too general and does not specifically address a family's concept of health and illness. Choice C, 'Family Health Belief Model,' is a combination of terms and not a recognized theory. Choice D, 'Family Dynamics Model,' focuses on family interactions rather than explaining a family's concept of health and illness.
A client who is immobilized secondary to traction is complaining of constipation. Which of the following medications should the nurse expect to be ordered?
- A. Advil
- B. Anasaid
- C. Clinocil
- D. Colace
Correct Answer: D
Rationale: The correct answer is Colace. Colace is a stool softener that helps relieve constipation by drawing more water into the bowel, making the stool softer and easier to pass. This is beneficial for an immobilized client as it can help prevent constipation due to decreased mobility. Options A, B, and C (Advil, Anasaid, Clinocil) are not indicated for constipation relief. Advil and Anasaid are nonsteroidal anti-inflammatory drugs used for pain relief, while Clinocil is a fictional medication.
Which of the following substances need to be assessed when completing a family health assessment?
- A. coffee, tea, cola, cocoa, and other substances
- B. alcohol, tobacco, and illegal substances
- C. medicines prescribed by a physician
- D. all of the above
Correct Answer: D
Rationale: When completing a family health assessment, it is essential to assess all substances consumed by family members, including coffee, tea, cola, cocoa, alcohol, tobacco, illegal substances, and medicines prescribed by a physician. Understanding the complete picture of substance use within the family is crucial for identifying potential health risks and providing appropriate care. Choice D, 'all of the above,' is the correct answer as it encompasses the comprehensive assessment of all substances. Choices A, B, and C are incorrect as they only present partial aspects of substance assessment and do not cover the full range of substances that should be evaluated in a family health assessment.