A nurse is caring for an elderly client living at home. What interventions can the nurse implement to reduce the client’s risk of falling? (Select all that apply)
Keep the stairs well-lit
Use shower chairs and raised toilet seats
Keep stairs free of clutter
Go upstairs swiftly while holding the side rail
Encourage the use of non-slip socks or shoes
Correct Answer : A,B,C,E
Adequate lighting is essential to help the client see the stairs and avoid tripping or falling. Using shower chairs and raised toilet seats can help the client maintain their balance while performing daily activities. Objects on the stairs can cause the client to trip and fall. Encouraging the use of non-slip socks or shoes can improve the client's grip and reduce the risk of slipping.
On the other hand, going upstairs swiftly while holding the side rail is not a recommended intervention as it can increase the risk of tripping or losing balance.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A complication that may result from decreased mobility is pressure injuries (also known as pressure ulcers or bedsores). When a person remains in one position for extended periods of time, the pressure from their body weight can cause damage to the skin and underlying tissues, particularly in bony areas.
Diarrhea, euphoria, and increased energy are not typically associated with decreased mobility. Diarrhea may be caused by a variety of factors such as infections, food intolerances, or certain medications. Euphoria and increased energy may be associated with certain medical conditions or drug use, but are not directly related to decreased mobility.
Correct Answer is A
Explanation
Bounding pulses are a feature of high cardiac output states such as pregnancy, thyrotoxicosis, anemia.
Coolness especially of the extremities is a sign of reduced perfusion to the extremities. Pallor is a sign of anemia and reduced perfusion due to low hemoglobin levels. Cyanosis is a feature of reduced oxygen supply which is a result of reduced perfusion.
Other signs of inadequate perfusion are hypotension, delayed capillary refill time, dry mucous membranes, poor skin turgor, restlessness, dysrhythmias, dizziness, tachycardia and diaphoresis.
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