during a home visit a nurse observes an older client who is attempting to ambulate to the bathroom and notes that the client is unsteady and holds on
Logo

Nursing Elites

HESI RN

HESI Community Health

1. During a home visit, a nurse observes an older client who is attempting to ambulate to the bathroom and notes that the client is unsteady and holds onto the furniture while refusing any assistance. Which action should the nurse implement?

Correct answer: A

Rationale: The correct action for the nurse to implement is to determine home navigational safety hazards. In this scenario, the client is unsteady and holds onto furniture while refusing assistance, indicating a risk of falls. By identifying and addressing home safety hazards, the nurse can help prevent potential accidents. Maintaining privacy in the bathroom (Choice B) is important but not the priority in this situation. Recommending a walker (Choice C) or a medical alert device (Choice D) may be appropriate interventions later but addressing home safety hazards is the immediate concern.

2. The nurse is assessing a client with pneumonia. Which finding requires immediate intervention?

Correct answer: C

Rationale: In a client with pneumonia, a heart rate of 90 beats per minute requires immediate intervention. Jugular vein distention indicates increased central venous pressure, suggesting possible complications like heart failure or fluid overload. Monitoring the heart rate closely and addressing any signs of heart failure promptly are crucial. A temperature of 99°F is within normal range and does not require immediate intervention. A respiratory rate of 20 breaths per minute is also normal. Fatigue is a common symptom in pneumonia but does not indicate an immediate need for intervention compared to the critical nature of jugular vein distention.

3. A client with a history of atrial fibrillation is receiving warfarin (Coumadin) therapy. Which laboratory result indicates that the therapy is effective?

Correct answer: D

Rationale: An International Normalized Ratio (INR) of 2.5 indicates that warfarin therapy is within the therapeutic range for a client with atrial fibrillation. A lower INR (such as 1.0) would suggest subtherapeutic levels, risking blood clots. Prothrombin time (PT) and partial thromboplastin time (PTT) are not specific to monitoring warfarin therapy.

4. A female client is admitted with a tentative diagnosis of Guillain-Barre syndrome. Which finding is most important for the nurse to report to the healthcare provider?

Correct answer: B

Rationale: In Guillain-Barre syndrome, decreased deep tendon reflexes are a critical finding that may indicate impending respiratory failure. This is due to the involvement of the peripheral nervous system affecting the muscles, including those involved in breathing. Reporting decreased deep tendon reflexes promptly is essential to prevent respiratory compromise. Facial weakness, difficulty speaking, and inability to move the eyes are common manifestations of Guillain-Barre syndrome but are not as immediately concerning as respiratory distress and impending respiratory failure.

5. A client with a head injury is admitted to the hospital. Which finding indicates a need for immediate intervention?

Correct answer: C

Rationale: In a client with a head injury, being drowsy but still arousable can be a sign of increased intracranial pressure, which necessitates immediate intervention. This presentation may indicate a deterioration in neurological status, requiring prompt assessment and management to prevent further complications. Choices A, B, and D are not indicative of an immediate need for intervention in this scenario. A Glasgow Coma Scale (GCS) score of 15 indicates the highest level of consciousness; pupils being equal and reactive to light suggest intact cranial nerve function, and memory loss about the injury event is common in head injuries and does not necessarily warrant immediate intervention.

Similar Questions

A client is suspected of being poisoned and presents with symmetric, descending flaccid paralysis, blurred vision, double vision, and dry mouth. The nurse should consider these findings consistent with which potential bioterrorism agent?
A client with a history of alcohol abuse is admitted with acute pancreatitis. Which assessment finding requires immediate intervention?
A first-grade boy is sent to the school nurse after he fainted while playing tag during recess. When he arrives in the clinic he is alert and oriented and his vital signs include temperature of 97.8°F, pulse 96 bpm, respirations 15 breaths/minute, and blood pressure 80/56 mmHg. Which intervention is most important for the nurse to implement?
The nurse is preparing to administer a scheduled dose of digoxin (Lanoxin) to a client. Which assessment finding should the nurse report to the healthcare provider?
A nurse is planning a community health fair to promote cardiovascular health. Which activity should be included to best engage participants?

Access More Features

HESI RN Basic
$69.99/ 30 days

  • 5,000 Questions with answers
  • All HESI courses Coverage
  • 30 days access

HESI RN Premium
$149.99/ 90 days

  • 5,000 Questions with answers
  • All HESI courses Coverage
  • 30 days access

Other Courses