A home health nurse is making a home visit to an older adult client. A nurse conducts a home safety assessment and screens the environment for potential hazards for falls. The nurse recommends that the client eliminate which of the following? (Select all that apply.)
Night lights
Excess clutter
Loose carpeting on the floors
Railings on the stairway
The use of a cane
Correct Answer : B,C
A. Night lights
Explanation: Night lights can enhance visibility during nighttime, reducing the risk of falls. The nurse may actually recommend using night lights strategically to illuminate pathways, especially in areas like hallways and bathrooms.
B. Excess clutter
Explanation: Excess clutter on floors can increase the risk of tripping and falling. Removing or organizing clutter helps create a safer environment for the older adult.
C. Loose carpeting on the floors
Explanation: Loose or wrinkled carpeting poses a tripping hazard. The nurse may recommend securing or replacing loose carpeting to prevent falls.
D. Railings on the stairway
Explanation: Railings on stairways are important safety features that provide support and stability. The nurse would likely recommend maintaining or installing railings to enhance stair safety.
E. The use of a cane
Explanation: If prescribed by a healthcare professional, the use of a cane can improve stability and balance for an older adult. The nurse may not recommend eliminating the use of a cane but may instead ensure that the client is using it correctly and that it is in good condition.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. The conservator will function in the same capacity as a health care proxy.
Explanation: A conservator and a health care proxy serve different roles. A conservator is appointed by a court to manage financial affairs, while a health care proxy is designated to make medical decisions on behalf of the individual if they are unable to do so. These roles are not interchangeable.
B. This client does not have the capacity to give informed consent for any procedures.
Explanation: The presence of a conservator alone does not automatically indicate a lack of capacity to give informed consent. Capacity for making healthcare decisions is determined on an individual basis and may vary depending on the client's cognitive and decision-making abilities.
C. The presence of a conservator does not mean the client cannot give informed consent.
Explanation: Having a court-appointed conservator to manage finances does not automatically imply that the client lacks the capacity to provide informed consent for medical procedures. The ability to make healthcare decisions, including giving informed consent, is distinct from financial capacity. Even if a conservator is appointed for financial matters, the client may still have the capacity to participate in decisions related to their health and medical treatment.
D. The nurse needs to provide all educational materials to the conservator instead of the client.
Explanation: Educational materials related to the client's healthcare should be provided directly to the client whenever possible. While the conservator may be involved in financial matters, the client should still receive relevant information regarding their health and medical care.
Correct Answer is B
Explanation
A. Four-length rails.
Explanation: Four-length rails fully enclose the bed and can be considered a more restrictive measure. They may be used when a restraint order is in place, but for an alert patient without such an order, less restrictive alternatives are preferred.
B. One-length rail.
Explanation: Using one-length rails can be a less restrictive alternative when a patient is at high risk for falling. The use of one side rail allows for some protection against falls without fully restraining the patient. This approach helps maintain the patient's mobility and autonomy while still providing a safety measure.
C. Two full-length rails.
Explanation: While using two full-length rails is less restrictive than four-length rails, it is still more restrictive than using only one side rail. The goal is to balance fall prevention with the patient's autonomy.
D. No side rails.
Explanation: Using no side rails may not provide adequate protection for an alert patient at high risk for falling. While avoiding restraints is essential, implementing at least one side rail is a reasonable compromise to enhance safety without fully restricting the patient's movement.
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