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 should store my personal items all together on the shelf in my bathroom.”
"I will wear a yellow wristband so everyone knows I am at risk of falling.”
"I should keep the overhead lights on at all times while I am here.”
"I will have to wear a restraint around my waist when I am sitting up in a chair.”
The Correct Answer is A
Choice A rationale:
Storing personal items together on a shelf in the bathroom promotes organization and reduces the risk of tripping or falling over scattered items. Keeping the environment tidy and free of clutter is an essential fall prevention strategy, especially in areas where the client moves frequently.
Choice B rationale:
Wearing a yellow wristband to indicate a fall risk is a common practice in healthcare facilities. However, merely wearing the wristband does not demonstrate a comprehensive understanding of fall prevention strategies. While it is essential for healthcare providers to identify patients at risk of falling, educating the patient about specific strategies to prevent falls is equally important.
Choice C rationale:
Keeping the overhead lights on at all times does not necessarily indicate an understanding of fall prevention strategies. While adequate lighting is important to prevent falls, leaving lights on continuously may not be necessary during daylight hours. It is more effective to ensure there is adequate lighting in commonly used areas and during nighttime hours.
Choice D rationale:
Wearing a restraint around the waist is not a recommended fall prevention strategy. Physical restraints are generally discouraged in healthcare settings due to ethical concerns and the potential to cause harm to the patient. Restraints can lead to complications such as pressure ulcers, loss of muscle strength, and decreased mobility.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale:
Repositioning the NG tube is not the appropriate action for hyperosmolar dehydration. This condition occurs due to an excessive concentration of solutes in the body, leading to a decrease in intracellular water. Repositioning the tube would not address the hyperosmolarity issue.
Choice B rationale:
Increasing the rate of formula delivery may exacerbate the problem by introducing more concentrated formula into the client's system, worsening hyperosmolarity. This choice can lead to further dehydration and electrolyte imbalances.
Choice C rationale:
Adding water to the formula is the correct action in this scenario. Hyperosmolar dehydration requires dilution of the concentrated formula to reduce the osmolarity. By adding water to the formula, the nurse can decrease the concentration of solutes, helping to rehydrate the client effectively.
Choice D rationale:
Switching to a lactose-free formula is not the appropriate intervention for hyperosmolar dehydration. The issue lies in the concentration of the formula, not in its lactose content. Adding water is the more suitable and direct approach to address the problem.
Correct Answer is B
Explanation
- A. Chest x-ray is not correct because it is not related to valproic acid therapy or its adverse effects.
- B. Serum liver enzyme levels is correct because valproic acid can cause hepatotoxicity and liver function tests should be monitored regularly.
- C. ABGS is not correct because it is not indicated for valproic acid therapy or its adverse effects.
- D. Urine culture and sensitivity is not correct because it is not related to valproic acid therapy or its adverse effects.
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