Difficulty: Medium
Average Score: 93%
Simulated
A home care nurse is visiting an older client recovering from a mild stroke affecting the left side. The client lives alone but receives regular assistance from the daughter and son, who both live within 10 miles. To assess for risk factors related to safety, which actions should the nurse take? Select all that apply.
Correct answer
A,B,C,D
Rationale
To conduct a thorough client assessment, the nurse assesses for possible risk factors related to safety. The assessment should include assessing visual acuity, gait and posture, and muscle strength because alterations in these areas place the client at risk for falls and injury. The nurse should also assess the home environment, looking for any hazards or obstacles that would affect safety. Asking a family member to move in with the client until recovery is complete and requesting that the client transfer to an assisted living environment for at least 1 month are not assessment activities. Additionally, nothing in the question indicates that these actions are necessary; therefore, these options are unrealistic and unreasonable.