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.

Answer and Explanation

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.

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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.

A. Fall history. B. Medical diagnosis. C. Use of assistive devices. D. Mental status. E. Do-not-resuscitate status.

Correct Answer is ["A"]

Explanation

Choice A rationale:

Maintaining the patency of the client's airway is the priority action. During a seizure, the client may lose consciousness and have difficulty breathing. Ensuring a clear airway is essential to prevent hypoxia and maintain oxygenation. This can be achieved by positioning the client on her side and removing any obstructions from her mouth to allow for adequate airflow.

Choice B rationale:

Identifying the poison the client ingested is important for providing appropriate medical treatment, but it is not the priority action in this scenario. Airway management takes precedence because it addresses the immediate threat to the client's life.

Choice C rationale:

Measuring the client's blood pressure is a necessary assessment, but it is not the priority during an active seizure. Airway management and seizure control are the immediate concerns. Once the seizure is controlled and the airway is secured, other assessments, including blood pressure measurement, can be performed.

Choice D rationale:

Positioning the client on her side is a correct action, but it should be done after ensuring the patency of the airway. Placing the client on her side helps prevent aspiration in case of vomiting during or after the seizure. However, it is not the priority over ensuring the client can breathe properly.

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A night shift nurse works and cares for several clients at risk for falls. Which of the following actions should the nurse take?

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Naxlex Comprehensive Predictor Exams

Which directional term means more toward the head or above another structure?

Correct Answer is A

Explanation

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Correct Answer is ["A"]

Explanation

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A night shift nurse works and cares for several clients at risk for falls.
Which of the following actions should the nurse take?