During a home visit, an elderly female client who had a brain attack three months ago and can now ambulate with a quad cane is assessed by the nurse. Which assessment finding has the greatest implications for this client's care?- Nurselytic

Question 1 of 5

During a home visit, an elderly female client who had a brain attack three months ago and can now ambulate with a quad cane is assessed by the nurse. Which assessment finding has the greatest implications for this client's care?

A. The husband, who is the caregiver, begins to weep when the nurse asks how he is doing. B. The client tells the nurse that she does not have much of an appetite today. C. The nurse notes that there are numerous scatter rugs throughout the house. D. The client's pulse rate is 10 beats higher than it was at the last visit one week ago.

Correct Answer: C

Rationale: The presence of numerous scatter rugs throughout the house poses a significant safety hazard to the client who is ambulating with a quad cane. These rugs increase the risk of tripping and falling, making it the most critical finding that needs immediate attention to prevent potential injuries and ensure the client's safety during ambulation.

Question 2 of 5

During a home visit, an elderly female client who had a brain attack three months ago and can now ambulate with a quad cane is assessed by the nurse. Which assessment finding has the greatest implications for this client's care?

A. The husband, who is the caregiver, begins to weep when the nurse asks how he is doing. B. The client tells the nurse that she does not have much of an appetite today. C. The nurse notes that there are numerous scatter rugs throughout the house. D. The client's pulse rate is 10 beats higher than it was at the last visit one week ago.

Correct Answer: C

Rationale: The presence of numerous scatter rugs throughout the house poses a significant safety hazard to the client who is ambulating with a quad cane. These rugs increase the risk of tripping and falling, making it the most critical finding that needs immediate attention to prevent potential injuries and ensure the client's safety during ambulation.

Question 3 of 5

When bathing an uncircumcised boy older than 3 years, which action should the nurse take?

A. Remind the child to clean his genital area. B. Defer perineal care due to the child's age. C. Retract the foreskin gently to cleanse the penis. D. Inquire about the reason for the child not being circumcised.

Correct Answer: C

Rationale: The correct action when bathing an uncircumcised boy older than 3 years is to gently retract the foreskin to cleanse the penis. This is important to ensure proper hygiene and prevent the accumulation of bacteria that can lead to infections. It is not advisable to defer perineal care because of the child's age, as hygiene is crucial at any age. Asking the parents about the circumcision status may not be relevant during routine perineal care. Reminding the child to clean his genital area is not as effective as directly cleaning the area during bathing.

Question 4 of 5

When assisting a client from the bed to a chair, which procedure is best for the nurse to follow?

A. Place the chair parallel to the bed, with its back toward the head of the bed, and assist the client in moving to the chair. B. With the nurse's feet spread apart and knees aligned with the client's knees, stand and pivot the client into the chair. C. Assist the client to a standing position by gently lifting upward underneath the axillae. D. Stand beside the client, place the client's arms around the nurse's neck, and gently move the client to the chair.

Correct Answer: B

Rationale: Option B is the best procedure for the nurse to follow when assisting a client from the bed to a chair. This option emphasizes the correct positioning of the nurse with feet spread apart and knees aligned with the client's, providing a stable base of support. By standing and pivoting the client into the chair, the nurse can maintain control and stability, especially around the client's knees, ensuring a safe transfer.

Question 5 of 5

A client with a suspected kidney infection is admitted to the hospital for observation. Which action should the nurse implement to assess the client's kidney function?

A. Monitor the client's urine output B. Check for abdominal tenderness C. Evaluate the client's fluid intake D. Inspect the client's skin for edema

Correct Answer: A

Rationale: Monitoring urine output is the most direct way to assess kidney function as it provides crucial information about the kidneys' ability to filter waste and produce urine. Changes in urine output can indicate potential issues with kidney function, such as decreased filtration or impaired excretion of waste products.

Nurselytic

HESI RN

HESI RN

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