A nurse is admitting a client who is at risk for falls to a medical-surgical unit. Which of the following actions should the nurse take?

Place the bedside table 0.9 m (3 feet) away from the bed.

Provide the client with a night light.

Elevate full-length side rails on both sides of the client's bed.

Keep the client's room temperature at 18° C (64.4° F).

Answer and Explanation

The Correct Answer is B

A. Place the bedside table 0.9 m (3 feet) away from the bed:

While having a bedside table nearby can be convenient for clients to access essential items, the specific distance of 0.9 m (3 feet) is not a standard guideline for falls prevention. Placing the bedside table closer to the bed may actually improve accessibility for the client, but it's not the most crucial action for falls prevention in this scenario.

B. Provide the client with a night light.

Falls prevention strategies aim to create a safe environment for clients at risk of falling. Providing a night light helps improve visibility during nighttime, reducing the risk of falls due to poor lighting. It assists clients in navigating their surroundings safely, especially when getting out of bed during the night.

C. Elevate full-length side rails on both sides of the client's bed:

Using full-length side rails on the bed can increase the risk of entrapment and injury, especially for clients at risk of falls. Current evidence suggests that the use of physical restraints, such as full-length side rails, does not effectively prevent falls and may contribute to adverse outcomes.

D. Keep the client's room temperature at 18°C (64.4°F):

While maintaining a comfortable room temperature is important for client comfort, the specific temperature of 18°C (64.4°F) is not a standard guideline for falls prevention. Instead, ensuring a comfortable temperature range based on individual client preferences and environmental factors is appropriate.

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Correct Answer is B

Explanation

A. "I will move your joints to the point of mild pain." - This statement is incorrect. Passive ROM exercises should not be performed to the point of causing pain. Pain during passive ROM exercises can indicate that the movement is too forceful or beyond the client's range of motion, which can lead to injury or discomfort.

B. "I will repeat these movements 3 to 5 times." - This statement is generally correct. Passive ROM exercises are typically repeated several times during each session to help maintain joint mobility and prevent contractures. The specific number of repetitions can vary based on the client's needs and tolerance.

C. "I will move your joints quickly." - This statement is incorrect. Passive ROM exercises should be performed slowly and gently to avoid causing discomfort or injury to the client. Slow movements allow for better control and precision, ensuring that the joints are moved through their full range of motion without undue force.

D. "These movements will be performed once per day." - This statement is incorrect. Passive ROM exercises are usually performed multiple times throughout the day, especially for clients with decreased mobility. Regular and frequent sessions help prevent stiffness, maintain flexibility, and promote circulation in the joints.

A. Phosphorous level B. Vitamin D level C. Smoking history D. Alcohol use E. Activity level F. Lactose intolerant

Correct Answer is ["B","E","F"]

Explanation

A. Phosphorous level: While phosphorus is important for bone health, deficiencies are rare in individuals with a normal diet and are not typically associated with osteoporosis.

B. Vitamin D level: Vitamin D is essential for calcium absorption and bone health. Inadequate vitamin D levels can lead to decreased calcium absorption and increase the risk of osteoporosis.

C. Smoking history: Smoking is a risk factor for osteoporosis due to its adverse effects on bone metabolism, but the client is a nonsmoker, so this finding does not apply.

D. Alcohol use: Excessive alcohol consumption is a risk factor for osteoporosis, but the client does not drink alcohol, so this finding does not apply.

E. Activity level: A sedentary lifestyle is a risk factor for osteoporosis. Weight-bearing exercises and physical activity help maintain bone density and strength, reducing the risk of osteoporosis.

F. Lactose intolerant: Lactose intolerance may lead to decreased intake of dairy products, which are a significant source of calcium. Inadequate calcium intake can contribute to decreased bone density and increase the risk of osteoporosis.

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A nurse is admitting a client who is at risk for falls to a medical-surgical unit. Which of the following actions should the nurse take?

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