A nurse is assisting with the development of a plan of care for an older adult who is at risk for falls. Which of the following actions should the nurse contribute to the plan? (Select all that apply)

Keep the bed at a comfortable working height.

Administer a sedative at bedtime.

Keep a night light on in the client's room and bathroom.

Place the bedside table within the client's reach.

Lock the wheels on beds and wheelchairs during transfers.

Answer and Explanation

Correct Answer : C,D,E

Keeping a night light on in the client's room and bathroom can help reduce the risk of falls by improving visibility and orientation at night. Placing the bedside table within the client's reach can help reduce the risk of falls by making it easier for the client to access necessary items without having to get up and move around. Locking the wheels on beds and wheelchairs during transfers can help reduce the risk of falls by providing stability and preventing unwanted movement.

a. Keeping the bed at a comfortable working height is important for the nurse's comfort and safety while providing care, but it does not directly reduce the risk of falls for the client.

b. Administering a sedative at bedtime may help the client sleep, but it can also increase the risk of falls by causing drowsiness and disorientation.

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Correct Answer is B

Explanation

The nurse should identify that developing a respiratory infection can cause a myasthenic crisis in a client who has myasthenia gravis. A myasthenic crisis is a sudden worsening of myasthenia gravis symptoms, which can include difficulty breathing and swallowing. Respiratory infections can exacerbate these symptoms and trigger a myasthenic crisis.

Taking too much-prescribed medication, insufficient exercise, and insufficient sleep are not factors that can cause a myasthenic crisis. Taking too much-prescribed medication can cause side effects but would not directly cause a myasthenic crisis. Insufficient exercise and insufficient sleep can worsen overall health but would not directly cause a myasthenic crisis.

A. Position the lower extremities so that they are touching B. Ensure that the client's heels are touching the bed. C. Prevent hip ﬂexion of the aﬀected extremity. D. Instruct the client to avoid movement of the aﬀected leg.

Correct Answer is C

Explanation

When contributing to the plan of care for a client who is postoperative following a total hip arthroplasty, the nurse should include information on preventing hip ﬂexion of the aﬀected extremity. This can help prevent dislocation of the new hip joint and promote healing.

Positioning the lower extremities so that they are touching is not necessary for a client who is postoperative following a total hip arthroplasty. The position of the lower extremities should be determined by the surgeon's instructions and the client's comfort.

Ensuring that the client's heels are touching the bed is not necessary for a client who is postoperative following a total hip arthroplasty. The position of the heels should be determined by the surgeon's instructions and the client's comfort.

Instructing the client to avoid movement of the aﬀected leg is not necessary for a client who is postoperative following a total hip arthroplasty. The client will need to begin moving and exercising the aﬀected leg as part of their rehabilitation and recovery.

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A nurse is assisting with the development of a plan of care for an older adult who is at risk for falls. Which of the following actions should the nurse contribute to the plan? (Select all that apply)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse in the emergency department is assisting with the care of a client who has myasthenia gravis and is in crisis. The nurse should identify which of the following factors can cause a myasthenic crisis.

Correct Answer is B

Explanation

A nurse is contributing to the plan of care for a client who is postoperative following a total hip arthroplasty. Which of the following information should the nurse include?

Correct Answer is C

Explanation

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