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A home health nurse is performing a home assessment for safety.
Which comment by the
patient will cause the nurse to follow up?
,a. "Every December is the time to change batteries on the carbon
monoxide detector."
b. "I will schedule an appointment with a chimney inspector next
week."
c. "If I feel dizzy when using the heater, I need to have it
inspected."
d. "When it is cold outside in the winter, I will use a nonvented
furnace." - Answer: ANS: D
Using a nonvented heater introduces carbon monoxide into the
environment and decreases
the available oxygen for human consumption and the nurse
should follow up to correct this
behavior. Checking the chimney and heater, changing the
batteries on the detector, and
following up on symptoms such as dizziness, nausea, and fatigue
are all statements that are
safe and appropriate and need no follow-up
The nurse is caring for an older-adult patient admitted with
nausea, vomiting, and diarrhea
due to food poisoning. The nurse completes the health history.
Which priority concern will
,require collaboration with social services to address the patient's
health care needs?
a. The electricity was turned off 3 days ago.
b. The water comes from the county water supply.
c. A son and family recently moved into the home.
d. This home is not furnished with a microwave oven. - Answer:
ANS: A
Electricity is needed for refrigeration of food, and lack of
electricity could have contributed to
the nausea, vomiting, and diarrhea due to food poisoning. This
discussion about the patient's
electrical needs can be referred to social services. Foods that are
inadequately prepared or
stored or subject to unsanitary conditions increase the patient's
risk for infections and food
poisoning, and an assessment should include storage practices.
The water supply, the
increased number of individuals in the home, and not having a
microwave may or may not be
concerns but do not pertain to the current health care needs of
this patient.
, The patient has been diagnosed with a respiratory illness and
reports shortness of breath.
The nurse adjusts the temperature to facilitate the comfort of the
patient. At which
temperature range will the nurse set the thermostat?
a. 60 ° to 64° F
b. 65 ° to 75° F
c. 15 ° to 17° C
d. 25 ° to 28° C - Answer: ANS: B
A person's comfort zone is usually between 18.3° and 23.9° C (65°
and 75° F). The other
ranges are too low or too high and do not reflect the average
person's comfort zone
A homeless adult patient presents to the emergency department.
The nurse obtains the
following vital signs: temperature 94.8° F, blood pressure 106/56,
apical pulse 58, and
respiratory rate 12. Which vital sign should the nurse address
immediately?
a. Respiratory rate
b. Temperature