A night shift nurse works and cares for several clients at risk for falls.
Which of the following actions should the nurse take?
Instruct the clients to use the call light.
Keep the clients' rooms dark.
Move overbed tables away from the bed.
Perform client checks every 4 hours.
The Correct Answer is A
The correct answer is A. Instruct the clients to use the call light.
Choice A rationale:
Instructing clients to use the call light ensures they can request assistance before getting up, which is a key strategy in preventing falls, especially during the night when visibility is reduced and the risk of disorientation is higher.
Choice B rationale:
Keeping the clients' rooms dark can increase the risk of falls as it makes it difficult for clients to see obstacles and navigate their environment safely. Adequate lighting is important for fall prevention.
Choice C rationale:
Moving overbed tables away from the bed can actually make it harder for clients to reach essential items and might increase the risk of falls if clients have to stretch or lean awkwardly to get what they need. The overbed table should be positioned within easy reach.
Choice D rationale:
Performing client checks every 4 hours is not frequent enough to effectively monitor at-risk clients. More frequent checks, such as hourly, are recommended to ensure safety and promptly address any needs that could prevent a fall.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale:
Pulse pressure is the difference between systolic and diastolic blood pressure and is not related to changing positions or the symptoms described in the scenario.
Choice B rationale:
Essential hypertension is a chronic medical condition characterized by elevated blood pressure levels persistently exceeding 140/90 mmHg. It is not directly related to positional changes or postural hypotension symptoms.
Choice C rationale:
Postural (orthostatic) hypotension occurs when a person experiences a sudden drop in blood pressure upon standing up from a sitting or lying position. This drop in blood pressure can lead to symptoms such as dizziness, lightheadedness, and fainting. Slowly changing positions is essential in managing postural hypotension because abrupt movements can worsen these symptoms. Educating the client about the importance of gradual position changes is crucial in preventing or minimizing postural hypotension-related symptoms.
Choice D rationale:
Pre-hypertension refers to blood pressure levels that are higher than normal but not high enough to be diagnosed as hypertension. It does not directly relate to the symptoms described in the scenario.
Correct Answer is A
Explanation
Choice A rationale:
Superior means more toward the head or above another structure. In anatomical terms, superior refers to a structure being closer to the head or higher than another structure in the body. For example, the head is superior to the neck because it is above the neck.
Choice B rationale:
Medial refers to the middle or near the middle of the body. It is used to describe structures that are closer to the midline of the body. For example, the nose is medial to the eyes because it is closer to the midline of the face.
Choice C rationale:
Ventral refers to the front or belly side of the body. It is opposite to dorsal, which refers to the back side of the body. Ventral structures are those that are located on the front side of the body, like the chest and abdomen.
Choice D rationale:
Caudal means toward the tail or inferior end of the body. It is opposite to superior and refers to structures that are located below or toward the tail end of the body. For example, the feet are caudal to the head because they are below the head.
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