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.

Answer and Explanation

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. *.

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Correct Answer is A

Explanation

Choice A rationale

Based on the client's statements, there is strong evidence of neglect and potential exploitation. Neglect is indicated by the inadequate food supply and minimal meal preparation. Financial exploitation is suggested by the client's lack of access to their retirement income, despite it being used for their care. This situation poses a serious risk to the client's well-being, triggering the nurse's ethical and legal duty to report suspected elder abuse to the appropriate authorities.

Choice B rationale

While gathering more information is often a good practice, directly questioning the adult child about financial matters could escalate the situation and potentially put the client at further risk. The primary responsibility of the nurse in this scenario is to ensure the client's safety, and the existing information is sufficient to warrant a report. The client has already provided a detailed account of the financial arrangement and their lack of access to funds, which is a key indicator of exploitation.

Choice C rationale

Educating the adult child about nutrition, while potentially helpful in some circumstances, does not address the immediate and serious issues of neglect and financial exploitation. The client's safety is the priority. Focusing solely on education ignores the broader pattern of abuse and the client's vulnerability, which requires a more direct and protective intervention.

Choice D rationale

Encouraging the client to speak with their adult child may place them in a more vulnerable position and could increase the risk of retaliation or further neglect. The client has already expressed an understanding of their adult child's frustration, and this approach fails to address the power imbalance and exploitative nature of the relationship. It is not an appropriate or safe intervention in a situation of suspected abuse. *.

A. Increase the rate of formula delivery. B. Add water to the formula. C. Switch to a lactose-free formula. D. Reposition the NG tube.

Correct Answer is B

Explanation

Choice A rationale

Increasing the rate of formula delivery would worsen hyperosmolar dehydration. A faster rate delivers more solute-rich formula to the gastrointestinal tract in a shorter time, pulling more free water from the body's vascular space into the gut lumen via osmosis. This fluid shift further depletes the body's free water, intensifying the dehydration and increasing serum osmolality.

Choice B rationale

Hyperosmolar dehydration occurs when the body's free water is drawn into the gastrointestinal tract due to a high solute concentration in the enteral formula. By adding free water to the formula, the nurse dilutes the solution, lowering its osmolarity. This action helps to balance the osmotic gradient, reducing the fluid shift and preventing further dehydration.

Choice C rationale

Switching to a lactose-free formula is indicated for clients with lactose intolerance, which causes symptoms like diarrhea and bloating, but it does not directly address hyperosmolar dehydration. Hyperosmolar dehydration is related to the overall solute load and concentration of the formula, not specifically the presence or absence of lactose.

Choice D rationale

Repositioning the NG tube is an action to ensure proper placement and prevent complications like aspiration, but it does not resolve hyperosmolar dehydration. This type of dehydration is a systemic problem related to fluid and electrolyte balance, not a local issue with the tube's position within the gastrointestinal tract. *.

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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?

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Naxlex Comprehensive Predictor Exams

Correct Answer is A

Explanation

A nurse is assessing a client who is receiving enteral feedings via an NG tube. The client has developed hyperosmolar dehydration. Which of the following actions should the nurse take when administering the client's feedings.

Correct Answer is B

Explanation

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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?