A nurse at an acute care facility is teaching a client about fall risk prevention strategies for use during their stay at the facility.
Which of the following statements by the client indicates an understanding of the teaching?
I will wear a color-coded wristband so everyone knows I am at risk of falling.
I will have to wear a restraint around my waist when I am sitting up in a chair.
I should store my personal items all together on the shelf in my bathroom.
I should keep the overhead lights on at all times while I am here.
The Correct Answer is A
Choice A rationale
A color-coded wristband, such as yellow, serves as a visual cue to all healthcare staff that a client has an increased risk of falling. This system promotes a universal understanding of the client's needs, allowing all members of the care team to implement appropriate fall prevention measures proactively and consistently, such as providing assistance with ambulation or frequent rounding.
Choice B rationale
The use of physical restraints, such as a restraint around the waist, is a last resort and requires a provider's order. It is not considered a primary fall prevention strategy. Restraints can increase a client's risk of injury and are associated with negative outcomes, including agitation, skin breakdown, and loss of muscle mass. Fall prevention strategies focus on proactive, non-restrictive interventions.
Choice C rationale
Storing personal items in a bathroom, especially on a high shelf, creates a significant fall hazard. The client may overreach or stand on a stool to retrieve items, increasing their risk of losing balance. To prevent falls, all personal items should be kept within easy reach of the client, such as on the bedside table, to minimize unnecessary movement.
Choice D rationale
While keeping some light on is helpful, having overhead lights on at all times can cause glare and create shadows that distort depth perception. This can make it difficult for a client with vision impairments to see potential obstacles. A low-level nightlight is a safer alternative for nighttime visibility, as it minimizes glare and helps maintain a normal sleep-wake cycle. *.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale
For a preschooler, play is the primary mechanism for coping and learning. A pounding board allows the child to express frustration and aggression in a safe, appropriate manner. This type of play helps to relieve tension and anxiety associated with hospitalization. It provides a healthy outlet for emotions that the child may not be able to articulate verbally, which is crucial for this developmental stage.
Choice B rationale
Preschoolers have a limited understanding of complex language. Using medical terminology can be frightening and confusing to them, increasing their anxiety. Nurses should use simple, concrete language that the child can understand, such as "checking your arm" instead of "taking your blood pressure," to help them feel more secure and cooperative with care.
Choice C rationale
Preschoolers thrive on routine and predictability. Establishing a new routine can be disruptive and increase their stress and fear. The nurse should strive to maintain as much of the child's home routine as possible to provide a sense of security and normalcy. This helps them feel more in control and less overwhelmed by the hospital environment.
Choice D rationale
A preschooler may experience separation anxiety when a parent leaves the room. Performing assessments while the parent is present helps the child feel more secure and supported. The parent can also provide comfort and help distract the child, which can make procedures easier and less frightening for the child. This promotes a trusting relationship between the child, parent, and nurse.
Correct Answer is A
Explanation
Choice A rationale
Flumazenil is a competitive antagonist for benzodiazepine receptors in the central nervous system. It works by blocking the effects of benzodiazepines, effectively reversing their sedative and anxiolytic effects. It is a specific antidote for benzodiazepine overdose and is indicated for the reversal of conscious sedation or for managing a benzodiazepine overdose. It should be used with caution due to the risk of seizures in long-term users.
Choice B rationale
Atropine is an anticholinergic medication primarily used to treat bradycardia (slow heart rate) and as an antidote for nerve agent or pesticide poisoning. It acts on muscarinic receptors to block the action of acetylcholine. It does not have any effect on benzodiazepine receptors and is therefore not the appropriate medication for treating benzodiazepine toxicity.
Choice C rationale
Activated charcoal is a general adsorbent used to treat certain oral poisonings and overdoses. It binds to the drug in the gastrointestinal tract, preventing its absorption into the bloodstream. It is only effective if administered early after ingestion of the drug. It is not a specific antidote for benzodiazepine toxicity, but a general measure to prevent absorption. Flumazenil is the specific antidote.
Choice D rationale
Naloxone is a narcotic antagonist that reverses the effects of opioid overdose by competing for the same receptor sites. It is specifically used for opioid toxicity and is ineffective for benzodiazepine overdose. Administering naloxone would not alter the effects of benzodiazepines and would be a completely inappropriate intervention for this type of toxicity.
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