A home health nurse is assessing an older adult client who reports falling a couple of times over the past week. Which of the following findings should the nurse suspect is contributing to the client's falls?
The client has a nonslip bath mat in his shower.
The client uses a raised toilet seat.
The client takes alprazolam.
The client wears fitted slippers.
The Correct Answer is C
A. A nonslip bath mat is a safety measure that should help prevent falls.
B. A raised toilet seat can help prevent falls by making it easier for the client to sit and stand.
C. Alprazolam, a benzodiazepine, can cause dizziness, drowsiness, and impaired coordination, increasing the risk of falls in older adults.
D. Wearing fitted slippers is generally a safety measure to prevent falls.
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Related Questions
Correct Answer is D
Explanation
A. Filling out an occurrence form is necessary but not the immediate priority.
B. Administering the medication to the correct client is important but not the immediate priority.
C. Notifying the provider is important but assessing the client's condition comes first.
D. Checking the client's vital signs is the immediate priority to ensure they are stable after the medication error.
Correct Answer is B
Explanation
A. While morphine can affect bowel sounds by causing constipation, this is not the priority assessment before administration.
B. Respiratory rate is the priority assessment because morphine can cause respiratory depression, which is a life-threatening side effect.
C. Urine output is important to monitor for overall kidney function and hydration status but is not the immediate priority before administering morphine.
D. Pupil reaction can indicate opioid effects, but monitoring respiratory status is more critical.
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