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
An acute hemolytic transfusion reaction is a severe and life-threatening reaction caused by an incompatibility between the donor's blood and the client's blood. The recipient's antibodies attack and destroy the transfused red blood cells, leading to hemolysis. The classic symptoms include chills, fever, low-back pain, tightness in the chest, and headache. This reaction is a medical emergency requiring immediate cessation of the transfusion and supportive care.
Choice B rationale
An allergic reaction to a blood transfusion is typically caused by the recipient's antibodies reacting to a foreign plasma protein in the donor blood. Symptoms can range from mild, such as hives and itching, to severe, such as anaphylaxis. However, symptoms like low-back pain and a feeling of "tightness" in the chest are more characteristic of a hemolytic reaction rather than a simple allergic response.
Choice C rationale
A febrile nonhemolytic transfusion reaction is the most common type of transfusion reaction. It is caused by the recipient's antibodies reacting to donor white blood cells. Symptoms include fever and chills, but typically do not include the severe manifestations of low-back pain, headache, and chest tightness that are seen in a hemolytic reaction. The reaction is usually not life-threatening.
Choice D rationale
Transfusion-related acute lung injury (TRALI) is a serious and potentially fatal complication of a transfusion. It is characterized by the sudden onset of non-cardiogenic pulmonary edema within six hours of a transfusion. Symptoms primarily involve respiratory distress, such as dyspnea and hypoxemia. While TRALI is severe, the symptoms presented, particularly the low-back pain and chest tightness, are more indicative of an acute hemolytic reaction. .
Correct Answer is B
Explanation
Choice A rationale
Visual disturbances are a less common side effect of risperidone and are not typically considered a priority finding. While they can be a nuisance for the client, they do not pose an immediate threat to the client's life. Other side effects require more immediate attention and intervention from the healthcare provider.
Choice B rationale
Risperidone can cause cardiac side effects such as QT prolongation, which can lead to life-threatening arrhythmias like Torsades de pointes. An irregular pulse is a critical finding that could indicate an underlying cardiac issue and requires immediate evaluation. This is a priority finding for the nurse to report to the provider.
Choice C rationale
Constipation is a common side effect of risperidone due to its anticholinergic properties. While it can cause discomfort, it is not an immediate life-threatening condition. The nurse should address this by encouraging fluid and fiber intake and possibly discussing a stool softener with the provider, but it is not the highest priority.
Choice D rationale
Dry mouth is a common and relatively benign side effect of risperidone. While it can cause discomfort and increase the risk of dental caries, it is not an urgent or life-threatening condition. The nurse can advise the client on strategies to manage this symptom, such as using sugar-free candies or chewing gum. *.
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