Nokea
The nurse is providing home care to an 89-year-old man. Which comments by the client indicate a need for further follow up? Select all that apply.
- A. Excuse me if my socks don't match. I can't tell blue from green anymore.
- B. Please don't open the blinds. It hurts my eyes when the sun is bright.
- C. Let me get my reading glasses so I can read that pamphlet.
- D. I don't hear so well, but I don't want a hearing aid. I'm too old to spend that kind of money on myself.
- E. Sometimes I have to check the calendar to be sure what day it is.
- F. My grandchildren call me 'old slowpoke' because I walk slower than they do.
Correct Answer: A,B,D,E
Rationale: Color vision loss, photophobia, hearing loss, and memory issues suggest potential medical issues (e.g., cataracts, glaucoma, hearing impairment, cognitive decline) requiring follow-up.
You may also like to solve these questions
The nurse is working with parents to plan home care for a 2 year-old with a heart problem. A priority nursing intervention would be to
- A. Encourage the parents to enroll in cardiopulmonary resuscitation (CPR) class
- B. Assist the parents to plan quiet play activities at home
- C. Stress to the parents the need to avoid overexertion
- D. Instruct the parents to avoid contact with persons with infection
Correct Answer: A
Rationale: Encourage the parents to enroll in cardiopulmonary resuscitation (CPR) class. While all suggestions are appropriate, the education of the parents/caregivers should include techniques of cardiopulmonary resuscitation in order to provide for emergency care of their child.
A man who had a cerebrovascular accident has expressive aphasia. Which approach will help communication the most?
- A. The nurse should write to the client and the client should write back.
- B. The nurse should anticipate the client's needs as much as possible.
- C. The nurse should encourage the client to speak as much as possible.
- D. A family member should stay with the client and express the client's needs to the nurse.
Correct Answer: C
Rationale: Encouraging speech practice aids communication recovery in expressive aphasia, fostering independence. Writing, anticipating needs, or relying on family are less effective.
A client taking isoniazid (INH) for tuberculosis asks the nurse about side effects of the medication. The client should be instructed to immediately report which of these?
- A. Double vision and visual halos
- B. Extremity tingling and numbness
- C. Confusion and lightheadedness
- D. Sensitivity of sunlight
Correct Answer: B
Rationale: Extremity tingling and numbness. Peripheral neuropathy is the most common side effect of INH and should be reported to the provider. It can be reversed.
An adult who has just been diagnosed with pulmonary tuberculosis asks the nurse how long he will have to be in isolation. What should be included in the nurse's reply?
- A. Isolation is for the duration of the treatment, which is at least 26 weeks.
- B. Isolation is necessary as long as the client has a cough.
- C. When the client has three negative sputum specimens, isolation is discontinued.
- D. When the evening fevers and night sweats subside, isolation is discontinued.
Correct Answer: C
Rationale: Isolation for pulmonary TB ends when three consecutive sputum samples are negative, indicating non-infectiousness, typically before the full 6-month treatment.
The nurse enters an adult's room to premedicate for surgery. The client says, 'You know, nurse, that form I signed said something about a nephrectomy. What does that mean?' How should the nurse respond initially?
- A. What did your surgeon explain to you about your operation?'
- B. Don't worry about the technical terms. We'll take good care of you.'
- C. I think you're just nervous about the surgery. This injection will make you feel calmer.'
- D. It is a kidney operation.'
Correct Answer: A
Rationale: Asking what the surgeon explained clarifies the client's understanding, ensuring informed consent and addressing concerns.