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 B
Explanation
If a client reports skin irritation around the upper edge of a lower-leg cast, the nurse should petal the edges of the cast. This involves applying adhesive strips or moleskin around the edges of the cast to smooth them out and prevent them from rubbing against the skin.
a. Suggesting that the client use a blunt object such as a comb to relieve the itch is not recommended as it can cause further irritation or damage to the skin.
c. Telling the client to apply lotion to the irritated skin is not recommended as it can cause further irritation or damage to the skin and may also damage the cast.
d. Bivalving the cast is not necessary for skin irritation around the upper edge of the cast. Bivalving involves cutting the cast in half to relieve pressure and is typically only done in cases of severe swelling or compartment syndrome.
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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