Nokea
The nurse performs a home safety survey for an individual with epilepsy. Click to specify the findings that require intervention by the nurse
- A. Multiple glass tables in the living room
- B. Multiple feather pillows present on the bed
- C. Padded covers on the edges of countertops
- D. Wall-to-wall carpeting was removed and replaced with scattered rugs on hardwood flooring
- E. Kitchen knives were readily accessible
- F. Client reports using the microwave instead of the stove
- G. Locks on the bathroom door
Correct Answer: A,D,E,G
Rationale: Glass tables, scattered rugs, accessible knives, and bathroom locks pose injury risks during seizures, requiring intervention.
You may also like to solve these questions
The nurse is caring for a 10-year-old child on the pediatric unit. The nurse, when caring for this age group, should be aware that:
- A. The child will do something for another person if that person does something for the child.
- B. The child now follows social standards for the good of all.
- C. The child wants to follow the rules because of a need to be seen as 'good.'
- D. The child finds satisfaction in following rules.
Correct Answer: C
Rationale: 10-year-olds are in Kohlberg’s conventional stage, seeking approval by following rules to be seen as 'good.' Reciprocity, societal good, or intrinsic satisfaction are less applicable.
The charge nurse is preparing for an influx of clients with measles (rubeola) in the emergency department. To prevent the spread of this infection, the nurse recommends
- A. The distribution of respirator masks (N95) to nursing staff.
- B. Disposable face shields outside client rooms.
- C. The placement of bleach wipes to disinfect commonly touched surfaces.
- D. The removal of alcohol-based hand rubs.
Correct Answer: A
Rationale: Measles requires airborne precautions, including N95 respirators for staff. Face shields, bleach wipes, and removing hand rubs are not specific to airborne transmission.
The nurse performs a home safety survey for an older adult. Click to specify the findings that require intervention by the nurse.
- A. Scatter rugs at the end of the stairs
- B. Smoke detector present without a battery
- C. Stairs present with sturdy hand rails
- D. New light fixtures installed and connected in a grounded electrical outlet
- E. Extension cord covered with an anti-skid area rug
- F. Unlabeled household chemicals under the sink
- G. Fire extinguisher present 30 feet from the stove
Correct Answer: A,B,E
Rationale: Scatter rugs and extension cords pose trip hazards, and a non-functional smoke detector is a fire risk. Unlabeled chemicals risk poisoning, requiring intervention.
Following scheduled radioactive iodine therapy in a nuclear medicine department, a nurse is speaking with a client following the client's ingestion of radioactive iodine regarding strategies to avoid radiating the client's family members. The nurse recognizes the need for additional client teaching when the client states:
- A. I understand the need to avoid sharing food or utensils with others.
- B. My children will miss my hugs and kisses for the next week.
- C. I'll travel for a couple of weeks to prevent my family from receiving radiation from me.
- D. I understand the need to flush the toilet with the lid closed two to three times after each use.
Correct Answer: C
Rationale: Traveling for weeks is excessive and unnecessary. Avoiding shared items, limiting close contact, and double flushing are appropriate to reduce radiation exposure.
The nurse is teaching a client who recently had a femoral vein central line catheter placed. Which of the following information should the nurse include?
- A. You will need to avoid drinking more than 500 mL per day.
- B. You will clean the site daily with soap and water.
- C. You should not sit up more than 45 degrees.
- D. You can remove the dressing if it becomes itchy.
Correct Answer: B
Rationale: Daily cleaning with soap and water maintains hygiene at the femoral central line site. Fluid restriction, angle limitation, and patient removal of dressings are incorrect and unsafe.