Nokea
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- A. Affect was flat, and the client appeared withdrawn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.
You may also like to solve these questions
The infection control nurse reviews guidelines with other nurses. Which of the following statements by the nurses would indicate a correct understanding of the teaching?
- A. The nurse should wear a surgical mask when transporting a client with active pulmonary tuberculosis (TB).
- B. Disposable utensils must be provided for a client infected with hepatitis B.
- C. A surgical mask should be worn when working within three feet of the client infected with Neisseria meningitidis.
- D. A surgical gown should be applied when entering a client's room with bacterial pneumonia.
Correct Answer: C
Rationale: Neisseria meningitidis requires droplet precautions, including a surgical mask within 3 feet. TB requires an N95 mask, hepatitis B does not need disposable utensils, and bacterial pneumonia requires standard precautions.
Which of the following clients would most likely benefit from contralateral stimulation as a nonpharmacological comfort intervention to decrease pain?
- A. A 36-year-old client with abdominal pain
- B. A 56-year-old client with a below-the-knee amputation and phantom limb pain
- C. A 76-year-old client with terminal cancer
- D. An 84-year-old client with severe arthritis
Correct Answer: B
Rationale: Contralateral stimulation, rubbing the opposite limb, is effective for phantom limb pain by altering pain perception. It is less effective for visceral, cancer, or arthritic pain.
Which hazardous gas can be identified in the home with a simple and relatively inexpensive monitor and alarm similar to a smoke alarm?
- A. Ozone
- B. Nitrous oxide
- C. Carbon monoxide
- D. Carbon dioxide
Correct Answer: C
Rationale: Carbon monoxide detectors are widely available, inexpensive, and similar to smoke alarms, detecting a colorless, odorless gas that poses a significant health risk. Ozone, nitrous oxide, and carbon dioxide detectors are less common in homes.
The nurse is observing the surgical aseptic technique of a nursing student. Which observation by the nurse requires follow-up?
- A. Spills sterile water onto the sterile field
- B. Uses sterile gloves to handle sterile supplies on a sterile field
- C. Has sterile gauze placed into the sterile field
- D. Keeps the sterile field above their waist
Correct Answer: A
Rationale: Spilling sterile water contaminates the sterile field, requiring follow-up. Other actions are consistent with aseptic technique.
The nurse is supervising a newly hired nurse preparing a client for a computed tomography (CT) scan of the brain with intravenous (IV) contrast. Which action by the newly hired nurse requires follow-up?
- A. Encouraging fluids when the client returns from the scan.
- B. Confirming that the consent form is signed.
- C. Raising the side rails of the client's stretcher during transport.
- D. Canceling the CT scan if the client reports a shellfish allergy.
Correct Answer: D
Rationale: Canceling the CT scan for a shellfish allergy is premature; further evaluation is needed. Encouraging fluids, confirming consent, and raising side rails are appropriate.