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 A

Explanation

The correct answer is choice A. The client requires total nursing care.

Choice A rationale:

A Glasgow Coma Scale (GCS) score of 8 indicates a severe head injury and significant impairment in consciousness. Clients with a GCS score of 8 or less are often unable to perform basic activities of daily living independently and require total nursing care.

Choice B rationale:

A GCS score of 8 does not indicate a deep coma. Deep coma is typically associated with a GCS score of 3-4, where the client shows minimal to no response to stimuli.

Choice C rationale:

A client who is alert and oriented would have a much higher GCS score, typically between 13 and 15. A score of 8 indicates significant impairment in consciousness, not alertness and orientation.

Choice D rationale:

A GCS score of 8 does not suggest stable neurological status. Instead, it indicates severe neurological impairment, requiring close monitoring and comprehensive care.

A. Pivot B. Hinge C. Ball and socket D. Gliding

Correct Answer is B

Explanation

The knee is a hinge type of joint. When describing range-of-motion exercises, the nurse should explain that the knee is a hinge joint. A hinge joint is a type of synovial joint that mainly allows for ﬂexion and extension (and a small degree of medial and lateral rotation)¹. The knee joint is formed by articulations between the patella, femur, and tibia¹.

a. The knee is not a pivot joint.

c. The knee is not a ball and socket joint.

d. The knee is not a gliding joint.

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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 is collecting data from a client who has a score of 8 using the Glasgow Coma Scale. Which of the following findings should the nurse expect?

Correct Answer is A

Explanation

A nurse is reinforcing teaching with a client who has a knee injury. When describing range-of-motion exercises, the nurse should explain that the knee is which of the following types of joints?

Correct Answer is B

Explanation

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