A nurse in a long-term care facility finds an older adult client lying on the floor next to the bed. Which of the following actions should the nurse take?
Check the client for injuries.
Obtain a prescription for medication to sedate the client.
Call the family and ask them to make arrangements for someone to sit with the client.
Assist the client back into bed and apply restraints.
The Correct Answer is A
The first action the nurse should take is to check the client for injuries. The nurse should assess the client for any signs of injury or trauma and provide appropriate care as needed.
Obtaining a prescription for medication to sedate the client, calling the family and asking them to make arrangements for someone to sit with the client, and assisting the client back into bed and applying restraints are not appropriate initial actions for the nurse to take in this situation. These actions may be considered after the client has been assessed for injuries and their immediate needs have been addressed.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
When contributing to the plan of care for a client to achieve the outcome of functional healing of a fracture, the highest priority nursing intervention to assist in meeting this outcome is to maintain immobilization and alignment for the client. This helps to ensure that the bones are in the correct position to heal properly and can prevent complications such as malunion or nonunion.
a. Promoting independence in activities of daily living for the client is important, but it is not the highest priority intervention for achieving functional healing of a fracture.
b. Providing relief from pain and discomfort for the client is important, but it is not the highest priority intervention for achieving functional healing of a fracture.
d. Providing optimal nutrition and hydration for the client is important, but it is not the highest priority intervention for achieving functional healing of a fracture.
Correct Answer is B
Explanation
Boutonniere deformity is an expected finding for a client who has rheumatoid arthritis. It is a type of hand deformity that can occur in people with rheumatoid arthritis. It is characterized by a bent middle finger joint and a hyperextended fingertip.
Tophi, osteoma, and Heberden's nodules are not expected findings for a client who has rheumatoid arthritis. Tophi are deposits of uric acid crystals that can occur in people with gout. Osteoma is a benign bone tumour. Heberden's nodules are bony growths that can occur in people with osteoarthritis.
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