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

Throw rugs in kitchen

Electrical cord on floor over walkway

Grab bar in bathroom

Macular degeneration

Answer and Explanation

Correct Answer : B,C,E

A.   While a cane can be helpful for balance, it doesn't necessarily increase fall risk. In fact, it can help reduce the risk.
B.   Throw rugs can be tripping hazards, especially for individuals with visual impairments like macular degeneration.
C.   Electrical cords can cause tripping and falls, especially in areas with high foot traffic.
D.   A grab bar can actually help prevent falls, especially in the bathroom where there is a risk of slipping.
E.   This eye condition can impair vision, making it difficult to see obstacles and potential hazards, increasing the risk of falls.

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Correct Answer is C

Explanation

A. This is a subjective indicator of pain. The pain rating is based on the client’s personal experience and perception of their pain intensity. It reflects the individual’s feelings rather than observable data.
B. This statement is also subjective. Describing pain as a "burning sensation" comes from the client's personal experience and interpretation of their symptoms, which cannot be measured or observed by others.
C. This is an objective indicator of pain. A grimace is an observable behavior that can indicate discomfort or pain. It is something that the nurse can see and assess, making it an objective finding.
D. This is another subjective indicator. While knowing the location of pain is important for diagnosis and treatment, the statement reflects the client’s personal experience of pain and cannot be measured or observed directly.

A. Elevate the head of the client's bed to 45° during meals. B. Instruct the client to tilt their head back while swallowing. C. Provide the client with oral hygiene. D. Turn on the television for the client during meals.

Correct Answer is A

Explanation

A. Elevating the head of the bed during meals can help prevent aspiration by allowing gravity to assist in keeping food and liquids in the esophagus rather than the airway. This position reduces the risk of aspiration pneumonia significantly for clients who may have swallowing difficulties.
B. Tilting the head back while swallowing can increase the risk of aspiration, as it can cause food or liquids to flow into the airway rather than the esophagus. Proper swallowing techniques usually involve tilting the head slightly forward or maintaining a neutral position.
C. While good oral hygiene is essential for overall health and can help reduce the risk of aspiration pneumonia by minimizing bacteria in the mouth, it is not a direct action during meal times that prevents aspiration. Oral hygiene is important but should be part of a comprehensive care plan.
D. Distractions during meals, such as watching television, can lead to decreased attention to swallowing and increase the risk of aspiration. It can divert the client’s focus from the act of eating, making it harder for them to manage their swallowing effectively.

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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.

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Naxlex Comprehensive Predictor Exams

A nurse is collecting data on a client for manifestations of pain. Which of the following findings is an objective indicator of pain?

Correct Answer is C

Explanation

A nurse is caring for a client who has dementia. Which of the following actions should the nurse take to reduce the client's risk of aspiration pneumonia?

Correct Answer is A

Explanation

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A charge nurse is reinforcing teaching with a newly licensed nurse about the advantages of electronic documentation. Which of the following information should the nurse include in the teaching?

What is the correct way to use a cane while walking?

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.