A nurse is caring for an older adult client who states, "I am afraid that I may fall while walking to the bathroom during the night." Which of the following actions should the nurse take?
Obtain a bedside commode for the client's use.
Limit the client's fluid intake in the evening.
Put the side rails up and tell the client to call the nurse before voiding.
Leave a nightlight on in the client's room.
The Correct Answer is D
A. Obtain a bedside commode for the client's use: While helpful, this might not address the client's fear of walking in a dark room, and it requires transferring, which could still pose a fall risk.
B. Limit the client's fluid intake in the evening: This can prevent nocturnal trips to the bathroom but doesn't directly address safety if the client needs to get up at night.
C. Put the side rails up and tell the client to call the nurse before voiding: Side rails can sometimes increase fall risk if the client attempts to climb over them. It's more beneficial to ensure a safe environment.
D. Leave a nightlight on in the client's room: This provides adequate lighting, reducing the risk of tripping or falling in the dark, which directly addresses the client's concern about safety while walking to the bathroom.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Covert: Covert data refers to information that is hidden, subjective, or not immediately observable, such as symptoms reported by the client. Voided volume is measurable and observable, so it is not covert.
B. Subjective: Subjective data is information reported by the client, such as feelings, perceptions, or symptoms. Since the urine output is a measurable and observable fact, it is not subjective.
C. Objective: Objective data is factual, measurable, and observable. The voided volume of 475 ml is a precise, quantifiable measurement, making it objective data.
D. Symptomatic: Symptomatic data pertains to symptoms experienced by the client, which are typically subjective. The documented urine output is a specific, quantifiable measurement and not a symptom.
Correct Answer is ["A","C","E","F"]
Explanation
A. Increased subcutaneous fat: Middle adulthood often sees an increase in fat deposits, particularly around the abdomen, due to changes in metabolism and hormonal shifts.
B. Increased skin turgor and moisture: Incorrect. Aging typically leads to decreased skin turgor and moisture, causing the skin to become drier and less elastic.
C. Decreased bone density: Bone density generally decreases due to reduced bone remodeling, increasing the risk of fractures and osteoporosis.
D. The skin is more elastic: Incorrect. Skin elasticity usually decreases with age, resulting in wrinkles and sagging.
E. Muscle mass gradually decreases: Muscle mass tends to decline with age, a condition known as sarcopenia, leading to reduced strength and physical capability.
F. Decreased auditory acuity: Hearing loss, particularly high-frequency hearing loss, is common as people age due to changes in the inner ear and other auditory structures
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