Nokea
The nurse is teaching a spouse how to care for a client who recently had a stroke and has residual weakness on the right side. Which style shoes should the nurse recommend the client wear when ambulating with the spouse's assistance?
- A. Tennis shoes with velcro.
- B. Rubber-soled slippers.
- C. Slip-on rubber shower shoes.
- D. Leather-soled loafers.
Correct Answer: A
Rationale: Velcro tennis shoes provide support and stability.
You may also like to solve these questions
The mother of a child born with Tetralogy of Fallot asks the nurse, 'Why did this happen to my baby? What did I do wrong?' Which response by the nurse is most helpful?
- A. This must be a very difficult time for you.'
- B. You did nothing wrong.'
- C. With surgery, your baby should have a full recovery.'
- D. Is there any particular reason why you think this is your fault?'
Correct Answer: A
Rationale: Empathy supports emotional expression without judgment.
History and physical
The client is a 44-year-old male with cerebral palsy who is non-verbal and has severe intellectual disability. He requires total care at home, which is provided by his two sisters, a home health nurse, and an unlicensed home health aide. The client is currently in the hospital for a lower respiratory infection.
Nurses notes
1000
Noted the client's clothes and sheets are wet. The client voided approximately 75 mL of urine. The client's sister says that he usually wears adult diapers at home as he is unable to communicate when he needs to void.
Review H and P and nurse's note.Complete the diagram by dragging from the choices area to specify which condition the client is most likely experiencing, two actions the nurse should take to address that condition, and two parameters the nurse should monitor to assess the client's progress.
- A. Create a toilet training program;Place an indwelling catheter;Place an incontinence containment product under the client;Teach the client to use mobility aids;Provide skin care
- B. Urge incontinence;Reflex urinary incontinence;Overflow urinary incontinence;Functional incontinence
- C. Intake and output;Blood pressure;Postvoid residual volume;Skin integrity;Blood glucose
Correct Answer:
Rationale: Overflow urinary incontinence: The client's condition, which includes wet clothes and sheets with a small volume of urine voided, suggests overflow urinary incontinence, where the bladder is not completely emptied and leaks small amounts of urine.
Place an incontinence containment product under the client: This action helps manage urinary incontinence by absorbing leaked urine and keeping the client dry, thereby preventing skin breakdown and discomfort.
Provide skin care: Regular skin care is essential to prevent skin irritation, breakdown, and potential infections, especially when the client is incontinent.
Intake and output: Monitoring intake and output is crucial in assessing the client's fluid balance and urinary function, ensuring that the incontinence is managed effectively.
Skin integrity: Monitoring skin integrity is necessary to identify any signs of pressure ulcers or skin breakdown, which can result from prolonged exposure to moisture due to incontinence.
The home health nurse is reviewing the personal care needs of an older adult client who lives alone. What client assessment finding(s) indicate(s) the need to assign an unlicensed assistive personnel (UAP) to provide routine foot care and file the client's toenails? Select all that apply.
- A. Hand tremors.
- B. Shuffling gait.
- C. Urinary incontinence.
- D. Diminished visual acuity.
- E. Syncope when bending.
Correct Answer: A,B,D
Rationale: Tremors, gait issues, and poor vision impair safe foot care.
When evaluating the effectiveness of a client's nursing care, the nurse first reviews the expected outcomes identified in the plan of care. What action should the nurse take next?
- A. Determine if the expected outcomes were realistic.
- B. Review related professional standards of care.
- C. Obtain current client data to compare with expected outcomes.
- D. Modify the nursing interventions to achieve the client's goals.
Correct Answer: C
Rationale: Comparing data assesses care effectiveness.
The nurse assesses that a client who is disoriented drank eight glasses of water in two hours and is continuing to drink excessive amounts of water. Because the nurse is concerned about water intoxication, which laboratory value should the nurse monitor?
- A. White blood cell count.
- B. Serum sodium levels.
- C. Serum potassium levels.
- D. Creatinine clearance.
Correct Answer: B
Rationale: Excess water dilutes sodium, risking hyponatremia.