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 A,B,C,D,E
Explanation
Trust vs. Mistrust (Birth to 1 year): In this stage, infants learn to trust or mistrust their caregivers and the world based on the consistency of care they receive.
Autonomy vs. Shame and Doubt (1 to 3 years): During this stage, toddlers learn to exercise will and to do things independently; failure to do so causes shame and doubt.
Initiative vs. Guilt (3 to 6 years): In this stage, children begin to assert control and power over their environment through directing play and other social interactions.
Industry vs. Inferiority (6 to 12 years): Here, children learn to read, write, and do things on their own. Peers and teachers become significant figures, and children strive to be competent and successful.
Identity vs. Role Confusion (12 to 18 years): Adolescents search for a sense of self and personal identity, through an intense exploration of personal values, beliefs, and goals.
Correct Answer is C
Explanation
A. Percussion: Percussion is typically performed before palpation. It helps to detect differences in density of abdominal contents, fluid presence, and gas patterns.
B. Auscultation: Auscultation is performed before any palpation or percussion to prevent altering bowel sounds. It is typically the second step after inspection.
C. Palpation: Palpation is used last during an abdominal assessment to prevent altering the characteristics of bowel sounds and to ensure that any tenderness or abnormal masses are identified after a thorough initial assessment. Palpation can cause changes in bowel sounds and tenderness.
D. Inspection: Inspection is always the first step in any physical examination. It allows for a visual assessment of the abdomen, looking for distension, asymmetry, and skin changes.
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