A nurse is assisting with the care of a client.

Exhibits
A nurse in a provider’s office is assisting with the review of fall risk data collected on a client. Which of the following findings places the client at risk for a fall? Select all that apply.

Uses a cane to ambulate.

Macular degeneration.

Grab bar in the bathroom

Electrical cord on floor over walkway.

Throw rugs over tile floors

Answer and Explanation

Correct Answer : B,D,E

Choice A reason : Using a cane to ambulate is generally a measure to improve stability and reduce the risk of falling for individuals who may have balance or mobility issues. It is not inherently a risk factor for falls; rather, it is a compensatory strategy to mitigate the risk of falls1.
Choice B reason : Macular degeneration can significantly impact visual acuity and contrast sensitivity, leading to difficulties in navigation and increasing the risk of tripping or misjudging distances. Poor vision is a well-documented risk factor for falls, especially in unfamiliar or complex environments.
Choice C reason : A grab bar in the bathroom is a safety device installed to provide stability and support for individuals while they are using the bathroom facilities. It is a preventive measure against falls and does not increase the risk of falling.
Choice D reason : An electrical cord on the floor over a walkway is a tripping hazard. It is a common home hazard that can cause falls, especially in the elderly or those with mobility and visual impairments78.
Choice E reason : Unsecured throw rugs over tile floors are a recognized fall hazard. They can easily slip underfoot or cause tripping if the edges are not secured, which is particularly dangerous in areas like the kitchen where spills can make the floor even more slippery.

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Correct Answer is D

Explanation

The correct answer is D. Wash the client’s body. This is a standard part of postmortem care to ensure the body is clean and presentable for the family and any further procedures.

Choice A reason:

Remove the client’s dentures. This statement is incorrect because dentures should be left in place to maintain the shape of the face and ensure a natural appearance for viewing by the family.

Choice B reason:

Increase the lights in the client’s room. This statement is incorrect because dim lighting is often preferred to create a calm and respectful environment for the family.

Choice C reason:

Place the head of the client’s bed flat. This statement is incorrect because the head should be elevated to prevent discoloration and pooling of blood.

Choice D reason:

Wash the client’s body. This is correct as it is a standard part of postmortem care to ensure the body is clean and presentable for the family and any further procedures.

A. Continue to talk to the client as if they are awake. B. Whisper when talking in the client's room. C. Limit the client's visitors to one at a time D. Avoid touching the client.

Correct Answer is A

Explanation

Choice A reason : Continue to talk to the client as if they are awake.Even when a client is unresponsive, they may still be able to hear and benefit from hearing a familiar voice. Continuing to talk to the client can provide comfort and reassurance during the end-of-life stage⁷.

Choice B reason : Whisper when talking in the client's room.Whispering can create a sense of secrecy and exclusion. It is important to communicate in a normal tone, respecting the client's presence and dignity⁷.

Choice C reason : Limit the client's visitors to one at a time.Limiting visitors can be appropriate in certain situations to maintain a calm environment; however, it should be based on the client's wishes and needs, not as a general practice⁷.

Choice D reason : Avoid touching the client.Appropriate touch can be comforting to an unresponsive client, conveying care and presence. It should not be avoided unless there is a specific reason to do so, such as pain or discomfort⁷.

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A nurse is assisting with the care of a client. Exhibits A nurse in a provider’s office is assisting with the review of fall risk data collected on a client. Which of the following findings places the client at risk for a fall? Select all that apply.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is providing postmortem care for a client. Which of the following actions should the nurse take?

Correct Answer is D

Explanation

A nurse is caring for a client who is at the end of life and is unresponsive. Which of the following actions should the nurse take?

Correct Answer is A

Explanation

A nurse is reinforcing teaching with a client who has diabetes mellitus about diabetic retinopathy. Which of the following statements should the nurse make?

A nurse is assisting with teaching a class about the long-term effects of childhood obesity. The nurse should include which of the following conditions as a potential complication of childhood obesity?

A nurse is planning to interview a client to determine their self-concept. Which of the following actions should the nurse plan to take first?

A nurse is assisting with teaching a client about over-the-counter medications used to treat insomnia. The nurse should include that which of the following is an adverse reaction of diphenhydramine?

A nurse is assisting with teaching a class about physical manifestations associated with the fight-or-flight response to stress. Which of the following manifestations should the nurse include?

A nurse is caring for a client who states, "I am under a great deal of stress at work, but I am able to forget my work and concentrate on my family when I get home at night." The nurse should identify that the client is demonstrating which of the following defense mechanisms?

A nurse is planning to use the nursing process to care for a client who is experiencing grief. Which of the following actions should the nurse take first?

A nurse is caring for an infant whose caregiver comforts them as soon as they cry. The nurse should identify that the client is experiencing which of the following stages of Erikson's theory of psychosocial development?

A nurse is assisting with the care of a client.

Exhibits
A nurse in a provider’s office is assisting with the review of fall risk data collected on a client. Which of the following findings places the client at risk for a fall? Select all that apply.