A charge nurse is observing a newly licensed nurse care for a client who is at risk for falls. Which of the following findings should the nurse identify as a risk factor for falls?
Positions the bedside table close to the client
Keeps the client's bed in the low position
Attaches the call light to the side rail of the client's bed
Instructs the client to wear their own socks to the bathroom
The Correct Answer is D
Choice A: This is incorrect because positioning the bedside table close to the client can help them reach their personal items and reduce the need to get out of bed.
Choice B: This is incorrect because keeping the client's bed in the low position can prevent injuries in case of a fall and make it easier for the client to get in and out of bed.
Choice C: This is incorrect because attaching the call light to the side rail of the client's bed can ensure that the client can access it easily and call for assistance when needed.
Choice D: This is correct because instructing the client to wear their own socks to the bathroom can increase the risk of slipping and falling. The client should wear non-skid footwear or slippers when walking.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A reason: Discouraging reminiscing about the past is not a helpful strategy for a client who has dementia and confusion. Reminiscing can stimulate memory, enhance mood, and promote social interaction.
Choice B reason: Asking open-ended questions that encourage the client to express their feelings is not appropriate for a client who has dementia and confusion. Open-ended questions can increase frustration and anxiety for the client who may have difficulty finding words or recalling events. The nurse should use simple, direct, and closed-ended questions instead.
Choice C reason: Using holiday decorations to provide orientation to the time of the year is a beneficial action for a client who has dementia and confusion. Holiday decorations can help the client recognize familiar cues and reduce disorientation.
Choice D reason: Encouraging multiple family members to visit the client at the same time is not advisable for a client who has dementia and confusion. Multiple visitors can overwhelm and agitate the client who may have trouble recognizing faces or voices. The nurse should limit the number of visitors and ensure they are calm and supportive.
Correct Answer is C
Explanation
Choice A reason: Doing testicular self-exam every 6 months without fail is not an adequate frequency, as it can delay the detection of any changes or abnormalities in the testes that may indicate cancer or other conditions. Men should perform testicular self-exam monthly, preferably after a warm bath or shower.
Choice B reason: The flu shot received last year will not last for 2 years, as it only provides protection against specific strains of influenza virus that may change from year to year. People should get a flu shot annually, preferably before the flu season starts.
Choice C reason: Examining breasts a week after each menstrual period is an optimal time, as breasts are less likely to be swollen, tender, or lumpy due to hormonal fluctuations. Women should perform breast self-exam monthly, preferably at the same time each month.
Choice D reason: Getting a hepatitis B vaccine on a yearly basis is not necessary, as it only requires three doses at 0, 1, and 6 months to provide lifelong immunity against hepatitis B virus infection. People who are at high risk of exposure to hepatitis B virus should get tested for antibodies before receiving the vaccine series.
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