The nurse is assessing a new patient admitted to home health. Which questions will be most appropriate for the nurse to ask to determine the risk of infection? (Select all that apply.)
"Have you traveled outside of the United States?"
"Will you demonstrate how to wash your hands?"
"Can you explain the risk for infection in your home?"
"What are the signs and symptoms of infection?"
"Are you able to walk to the mailbox?"
"Who runs errands for you?"
Correct Answer : A,B,C,D
A. Asking about travel outside the United States helps identify potential exposure to infections that are more prevalent in certain areas.
B. Assessing handwashing techniques is crucial, as proper hand hygiene is a fundamental way to prevent infections.
C. Understanding the patient's perception of infection risk in their home environment can highlight potential areas for intervention.
D. Knowing the signs and symptoms of infection allows the nurse to evaluate the patient’s awareness and ability to recognize early signs of infection.
E. While mobility can affect overall health, it is not directly related to assessing the risk of infection.
F. Knowing who runs errands may provide context for the patient's support system, but it does not directly assess infection risk.
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Correct Answer is A
Explanation
A. Hyperkalemia can lead to dangerous cardiac arrhythmias and other heart-related complications due to its effect on the electrical conduction system of the heart, making cardiac assessment the priority.
B. While neurological assessment is important in various conditions, it is secondary to assessing cardiac status in hyperkalemia.
C. Gastrointestinal symptoms can occur with hyperkalemia, but they do not pose an immediate life-threatening risk like cardiac issues do.
D. Respiratory assessment is essential in many contexts, but the immediate threat of hyperkalemia lies in its impact on heart function, making cardiac assessment the most critical.
Correct Answer is C
Explanation
A. While metabolic acidosis is a potential concern for some diabetic conditions, avoiding acidic foods is not a common dietary guideline for managing diabetes.
B. Including dairy can contribute to calcium intake but does not directly impact diabetes management.
C. Staying hydrated is essential for overall health and helps regulate blood sugar levels, making it an appropriate dietary recommendation for this patient.
D. Since the patient does not require insulin, strict carbohydrate reduction may not be necessary, making this option less relevant.