Nokea
The nurse is participating in a committee reviewing strategies to reduce falls in older adults. Which of the following recommendations by the nurse would be appropriate to make?
- A. Increase the availability of bedside commodes
- B. Recommend the occupational therapist assess the client for mobility and safety
- C. Reduce environmental lighting, especially at night
- D. Remove grab bars from the bathrooms
Correct Answer: A,B
Rationale: Bedside commodes and occupational therapy assessments reduce fall risk by improving access and mobility. Reducing lighting and removing grab bars increase fall risk.
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The nurse is teaching progressive relaxation techniques to a client. Which of the following statements by the client indicates that the teaching has been effective? Select all that apply.
- A. I will breathe in and out in rhythm.
- B. I expect my pulse to be faster afterwards.
- C. I expect to require less pain medication.
- D. I expect my muscles to feel less tense.
- E. I will report any increased sensitivity.
Correct Answer: A,C,D
Rationale: Rhythmic breathing, reduced pain medication needs, and muscle relaxation indicate effective relaxation. Faster pulse and increased sensitivity are incorrect expectations.
The nurse provides discharge teaching to a client prescribed a cane for left-sided weakness. Which instruction should the nurse provide?
- A. Advance the cane along with your stronger leg.
- B. Remove the rubber tip when going upstairs.
- C. Measure the height of the cane to your elbow.
- D. Secure the cane in your right hand.
Correct Answer: D
Rationale: The cane is held in the right hand (stronger side) for left-sided weakness to support the weaker leg. The stronger leg moves first, rubber tips stay on, and height is measured to the greater trochanter.
The nurse is performing an initial home health visit on a client who had a stroke one week ago with left-sided hemiparesis. Select the findings in the admission note that require follow-up.
- A. Affect was flat, and the client appeared withdrawn
- B. The client reported full adherence to their prescribed medications
- C. The client reported that they missed two physical therapy appointments.
- D. The client reported that they removed the cane's rubber tip because it left marks on their flooring.
- E. The client ambulated with the cane and held it in their right hand.
- F. The client advanced the cane 12-14 inches (30-36 cm) with each step
Correct Answer: A,C,D
Rationale: Flat affect, missed therapy, and removed rubber tip indicate depression, non-adherence, and safety risks, needing follow-up. Medication adherence, correct cane use, and proper advancement are appropriate.
The nurse is admitting a client diagnosed with hepatitis B. The nurse would be able to cohort the client in the same room with which of the following clients? A client with
- A. Heart failure receiving diuretics
- B. Bacterial meningitis receiving antibiotics
- C. Prostate cancer receiving brachytherapy
- D. Varicella prescribed antivirals
Correct Answer: A
Rationale: Hepatitis B is transmitted via blood/body fluids, so rooming with a heart failure client is safe. Meningitis, varicella, and brachytherapy require specific precautions or isolation.
The nurse is interviewing a 25-year-old female client who recently experienced domestic violence. What is the rationale for excluding the family from the interview to ensure a safe and confidential environment? Select all that apply.
- A. Promote client autonomy
- B. Maintain family dynamics and support
- C. Maintains privacy and confidentiality
- D. Prevent potential intimidation or coercion
- E. Minimize the risk of retaliation
Correct Answer: A,C,D,E
Rationale: Excluding family promotes autonomy, privacy, and prevents intimidation or retaliation. Maintaining family dynamics is not a priority in this context.