Correct Answer: C

Rationale: The most appropriate action for the home health nurse to take in this situation where a patient reports distortions when looking at an Amsler grid is to arrange for the patient to be assessed for macular degeneration. Distortions in straight lines on an Amsler grid are a common early symptom of macular degeneration, a progressive eye condition that affects central vision. Macular degeneration is a leading cause of vision loss in older adults, making assessment and early intervention crucial in preserving vision. It is important for the nurse to take the patient's symptoms seriously and facilitate timely evaluation and management to prevent further vision loss. This would involve referring the patient to an ophthalmologist or an eye care specialist for a comprehensive evaluation and appropriate treatment.

Correct Answer: A

Rationale: The statement "If I get a blue color that means the test is negative" given by the patient indicates the need for further education. This is incorrect information because a blue color in the guaiac test indicates a positive result, which means the presence of fecal occult blood. The patient should be taught that a positive result indicates the need for further evaluation and follow-up with their healthcare provider. Proper understanding of the test results is vital to ensure accurate interpretation and appropriate management. Further clarification and education are necessary to correct this misconception and guide the patient towards understanding the significance of a positive result.

Correct Answer: B

Rationale: Superior vena cava syndrome (SVCS) is a medical emergency that can occur in patients with advanced cancer, such as breast cancer with metastasis. SVCS is caused by the obstruction or compression of the superior vena cava, a large vein that carries blood from the upper body back to the heart. When the superior vena cava is obstructed or compressed, it can lead to symptoms such as difficulty breathing (dyspnea) and distended jugular veins.

Correct Answer: B

Rationale: It is crucial for the nurse to monitor that all furniture remains in the same position in the hospitalized patient's room. For a patient with impaired vision who needs to create a mental picture of the room to mobilize independently and safely, any changes in the position of furniture can disrupt this mental map and potentially lead to accidents or falls. By ensuring that all furniture remains unchanged, the nurse supports the patient's ability to navigate the room confidently and without obstacles. This monitoring helps promote the patient's safety and independence during their stay in the hospital.

Correct Answer: D

Rationale: SBAR stands for Situation, Background, Assessment, and Recommendation. It is a structured method of communication that healthcare providers use to effectively communicate important information about a patient. The use of SBAR helps ensure that all necessary details are communicated in a clear, concise, and systematic manner, reducing the risk of miscommunication and errors. By standardizing communication using SBAR, nurses can provide a comprehensive report during a shift change, promoting continuity of care and patient safety. Thus, the main rationale for a nurse using SBAR when providing a hands-off report is to standardize communication and improve the quality of patient care.