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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
The correct answer is choice c. “I am thankful I am done having children.”
Choice A rationale: This statement is incorrect because a vaginal hysterectomy involves the removal of the uterus, which means the client will no longer have menstrual periods.
Choice B rationale: This statement is incorrect because even after a hysterectomy, regular gynecological examinations are still necessary to monitor the health of the remaining reproductive organs and overall health.
Choice C rationale: This statement indicates that the client understands the implications of the surgery, specifically that they will no longer be able to have children, which is a key aspect of informed consent for a hysterectomy.
Choice D rationale: This statement is incorrect because a vaginal hysterectomy does not involve an abdominal incision, so there will not be a large scar on the stomach. The procedure is performed through the vagina.
Correct Answer is D
Explanation
A. Incorrect. Weight loss is not a manifestation of fluid overload but rather of insufficient nutrition.
B. Incorrect. Decreased blood pressure is not a manifestation of fluid overload but could indicate hypovolemia.
C. Incorrect. Decreased skin turgor is a sign of dehydration, not fluid overload.
D. Correct. Crackles heard in the lungs can indicate fluid overload in the lungs, also known as pulmonary edema. This is often caused by an excess of fluid in the body.
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