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
The herpes zoster vaccine, also known as the shingles vaccine, is specifically recommended for older adults. The incidence and severity of shingles, which is caused by the reactivation of the varicella-zoster virus, increase significantly with age, particularly after 50 years. The vaccine works by boosting the immune response to the virus, thereby reducing the risk of developing shingles and the associated long-term neuropathic pain.
Choice B rationale
The human papillomavirus (HPV) vaccine is recommended for individuals up to age 26, with a primary target age of 11 or 12. It is not typically recommended for older adults because most have already been exposed to the virus, and the vaccine is most effective before sexual activity begins. The immune response in older adults is also less robust than in younger individuals, making the vaccine less effective in this population.
Choice C rationale
The rotavirus vaccine is recommended for infants and young children, usually in a series of doses starting at 2 months of age. Rotavirus is a common cause of severe diarrhea in infants and young children, but it does not pose a significant health threat to older adults. The vaccine is not indicated for older adults because they have usually developed immunity from previous exposures to the virus.
Choice D rationale
Diphtheria, tetanus, and acellular pertussis (DTaP) vaccine is primarily given to infants and young children in a series of doses. For older adults, the Tdap or Td booster is recommended. The Tdap vaccine provides protection against tetanus, diphtheria, and pertussis, which is important for older adults as their immunity wanes over time. However, the DTaP formulation is not the one typically recommended for this age group. .
Correct Answer is D
Explanation
Choice A rationale
Using clean technique for invasive procedures in a neutropenic client is insufficient. Neutropenia is a severe reduction in neutrophils, a key component of the immune system, leaving the client highly susceptible to infection. Aseptic or sterile technique, rather than clean technique, is necessary for all invasive procedures to prevent the introduction of pathogens. This includes strict hand hygiene, sterile gloves, and sterile fields to minimize infection risk.
Choice B rationale
Allowing healthy children to visit is a dangerous practice for a neutropenic client. Children, even those appearing healthy, can carry and transmit pathogens like viruses and bacteria that their developing immune systems can easily fight off. In a client with neutropenia, however, these common microorganisms can cause severe, life-threatening infections due to the lack of an adequate immune response. Therefore, visitors must be carefully screened.
Choice C rationale
Cleaning the client's room every 2 days is an inadequate frequency for a neutropenic client. An environment with reduced pathogen exposure is crucial for these immunocompromised clients. The room should be cleaned daily to minimize the accumulation of dust, dirt, and microorganisms. All surfaces, including floors, tables, and equipment, must be disinfected to reduce the risk of nosocomial infections and maintain a sterile environment.
Choice D rationale
Neutropenia impairs the body's ability to mount a fever response to infection. Therefore, a low-grade temperature elevation may be the only sign of a serious infection. Monitoring the client's temperature frequently, typically every 4 hours, is a critical nursing intervention. Early detection of a fever, even a slight one, allows for prompt initiation of antibiotics and other treatments, significantly improving the client's prognosis and preventing a potential septic shock. *.
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