A home health nurse is providing teaching to an older adult client who is at risk for falls.
Which of the following statements by the client indicates a need for further teaching?
"I will have my vision checked."
"I will put socks on when I get out of bed."
"I will put a safety bar near my toilet."
"I will put a night-light in the hallway."
The Correct Answer is B
A. Having vision checked is a positive step to prevent falls by addressing potential visual impairments.
B. Wearing socks when getting out of bed increases the risk of slipping, indicating a need for further teaching.
C. Placing a safety bar near the toilet is a preventive measure against falls.
D. Putting a night-light in the hallway helps improve visibility and reduce the risk of tripping
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. The two-point gait requires partial weight-bearing on both legs, making it unsuitable for a client who can only bear weight on one leg.
B. The four-point gait also requires weight-bearing on both legs and provides maximum stability, but it is not appropriate for a client who can bear weight on only one leg.
C. The swing-through gait is generally used by clients with paralysis of the legs or for those who need to use both legs minimally while moving with crutches. It is not the most suitable option for a client with weight-bearing restrictions on one leg.
D. The three-point gait is the correct technique for a client who can bear weight on only one leg. In this gait, both crutches and the affected leg are moved forward together, followed by the weight-bearing leg. This method allows the client to ambulate safely while maintaining the non-weight-bearing leg off the ground.
Correct Answer is B
Explanation
A. Palpating the abdomen may exacerbate pain or cause discomfort, and it is not the first action in the assessment of a client with suspected appendicitis. Auscultating bowel sounds is a more appropriate initial step.
B. Auscultating bowel sounds is the priority to assess for signs of bowel obstruction or ileus, which can contribute to the client's symptoms.
C. Offering pain medication can be addressed after the initial assessment and determination of the cause of the symptoms.
D. Administering an antibiotic is premature before a diagnosis is confirmed. The priority is to assess and gather information first.
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