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?

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

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

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

Provide the client with a night light.

Answer and Explanation

The Correct Answer is D

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

While side rails are used to prevent falls, full-length side rails can pose a risk to the client. They may give a false sense of security, and there's a risk of entrapment or injury if the client tries to climb over them. The use of side rails requires careful assessment and consideration of the individual client's needs.

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

Placing the bedside table 0.9 m (3 feet) away from the bed may not directly address the risk of falls. The focus should be on making essential items easily accessible to the client to minimize the need for them to get out of bed, especially during the night. Placing items within the client's reach is a more practical approach.

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

While maintaining a comfortable room temperature is important for the client's overall well-being, it is not a direct preventive measure for falls. Falls are more likely to be prevented by addressing environmental factors, ensuring clear pathways, and providing adequate lighting.

D. Provide the client with a night light:

This is the appropriate action. A night light helps improve visibility during nighttime, reducing the risk of falls. It allows the client to see their surroundings better and navigate the room safely if they need to get out of bed.

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Correct Answer is B

Explanation

A. "Increase intake of vitamin B12":

Vitamin B12 is important for various bodily functions, including the health of nerves and red blood cells, but it is not directly associated with osteoporosis prevention. Calcium and vitamin D are more critical nutrients for bone health.

B. "Walk for 30 minutes three to five times each week":

Weight-bearing exercises, such as walking, are beneficial for preventing osteoporosis. Weight-bearing activities stimulate bone formation and help maintain bone density. Regular walking for 30 minutes, three to five times per week, can contribute to overall bone health and reduce the risk of osteoporosis.

C. "Perform water aerobics three times each week":

While water aerobics is a beneficial exercise for cardiovascular health and joint flexibility, it is not as effective as weight-bearing exercises for preventing osteoporosis. Weight-bearing activities put stress on bones, promoting bone density.

D. "Maintain a lean body mass":

Maintaining a healthy body weight and lean body mass is important for overall health, but it is not a direct preventive measure for osteoporosis. Weight-bearing exercises and adequate intake of calcium and vitamin D are more specific recommendations for preventing osteoporosis.

A. Cholestrol level B. Prealbumin level C. History of malnutrition D. History of diabetes mellitus E. History of hyperlipidemia)

Correct Answer is ["B","C","D"]

Explanation

A. Cholesterol level:

While hyperlipidemia (elevated cholesterol levels) is associated with cardiovascular disease, it is not a direct factor affecting wound healing. Cholesterol levels primarily impact vascular health and are not directly related to the cellular and tissue processes involved in wound repair.

B. Prealbumin level:

Prealbumin is a protein that reflects recent dietary intake and nutritional status. Low prealbumin levels can indicate malnutrition, which is associated with delayed wound healing. Adequate protein intake is crucial for tissue repair and wound healing.

C. History of malnutrition:

Malnutrition is a significant risk factor for delayed wound healing. Adequate nutrition is essential for the body to carry out the processes involved in wound healing, including cell proliferation, collagen synthesis, and immune function.

D. History of diabetes mellitus:

Diabetes mellitus can impair wound healing due to factors such as reduced blood flow, impaired immune response, and neuropathy. Elevated blood sugar levels in diabetes can interfere with the normal healing processes, leading to delayed wound healing.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is preparing to teach a female client about osteoporosis prevention. Which of the following recommendations should the nurse make for this client?

Correct Answer is B

Explanation

Client has a history of malnutrition, hyperlipidemia, and diabetes mellitus. The nurse is reviewing the client's medical record. Which of the following findings places the client at risk for delayed wound healing? Select all that apply.

Correct Answer is ["B","C","D"]

Explanation

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