A home health nurse is conducting a home inspection for a client who is at risk for falls. Which of the following instructions should the nurse provide for the client?

Place the bedside table 2 feet away from the bed.

Move the client's bed to the main floor of the house.

Keep lighting in the home dim.

Place area rugs on slick floor surfaces.

Answer and Explanation

The Correct Answer is B

A.   Incorrect. The bedside table should be within easy reach of the bed to prevent the client from attempting to reach for items and potentially falling.
B.   Correct. Moving the client's bed to the main floor of the house reduces the need for using stairs, which can be a fall risk for clients at risk for falls.
C.   Incorrect. Keeping the lighting dim increases the risk of falls. Adequate lighting is important to prevent falls.
D.   Incorrect. Area rugs on slick floor surfaces can be hazardous and increase the risk of falls.
They should be removed or secured properly.

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Correct Answer is C

Explanation

Answer is:Drain the tub water before the client gets out.

Explanation: This is the correct answer because it reduces the risk of slipping and falling for the client, especially if they have limited mobility or balance problems. The other options are incorrect because:

Checking on the client every 10 min during the bath is not enough to ensure their safety and comfort.The nurse should check on them more frequently, such as every 5 to 10 minutes, depending on their needs and preferences.
Adding bath oil to the water after the client gets into the tub is not a good idea because it can make the water slippery and increase the risk of falling.The nurse should add bath oil to the water before the client gets into the tub, or use a non-slip mat or shower chair.
Allowing the client to remain in the bath for 30 min is too long and can cause dehydration, hypothermia, or skin irritation.The nurse should instruct the client to remain in the tub for no longer than 20 min, unless otherwise ordered by a physician.

A. "Lie down and I will stroke the bottom of your foot." B. "Sit on the edge of the bed while I tap your knee." C. "Place your foot in my hand and I will tap the back of your heel." D. "Relax your arm across your chest and I will test your elbow extension."

Correct Answer is A

Explanation

A. Correct. The plantar Babinski reflex is elicited by stroking the sole of the foot along the lateral aspect, from the heel to the ball of the foot. The nurse's instruction to the client is accurate.
B. Tapping the knee is related to the knee jerk reflex, not the Babinski reflex.
C. Tapping the back of the heel does not elicit the plantar Babinski reflex.
D. Testing elbow extension is unrelated to the Babinski reflex.

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A home health nurse is conducting a home inspection for a client who is at risk for falls. Which of the following instructions should the nurse provide for the client?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is A

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