A nurse is collecting data regarding home safety from a client who is prone to falls. Which of the following findings should the nurse recognize as placing the client at additional risk?
The client has removed the wheels from rolling chairs.
A stool riser is in place on the bathroom toilet.
The client’s mattress is directly on the floor.
Throw rugs cover electrical cords on the floor.
The Correct Answer is D
Choice A reason: Removing the wheels from rolling chairs is a good practice to prevent the chairs from sliding or moving unexpectedly. It is not a risk factor for falls, but rather a safety measure to prevent them.
Choice B reason: A stool riser is a device that elevates the toilet seat and makes it easier for the client to sit down and stand up. It is not a risk factor for falls, but rather a safety measure to prevent them.
Choice C reason: Having the mattress directly on the floor may make it harder for the client to get in and out of bed, but it does not increase the risk of falls. In fact, it may reduce the risk of injury if the client falls from the bed, as the height is lower.
Choice D reason: Covering electrical cords with throw rugs is a risk factor for falls, as the client may trip over them or get tangled in them. It is also a fire hazard, as the rugs may overheat or catch fire from the cords. The nurse should advise the client to remove the rugs and secure the cords away from the walking areas.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A reason: This is not the correct answer because the FLACC scale is designed for infants and children who are unable to verbalize their pain, not for adults who speak a different language.
Choice B reason: This is not the correct answer because asking an assistive personnel to interpret is not a reliable or ethical way of communicating with the client. The nurse should use a professional interpreter or a certified bilingual staff member.
Choice C reason: This is the correct answer because a communication board is a simple and effective way of assessing the client's pain level and location.
Choice D reason: This is not the correct answer because the FACES pain scale is based on facial expressions that may vary across cultures and languages. The client may not understand or relate to the pictures on the scale.
Correct Answer is D
Explanation
Choice A reason: Turning on loud music in client care areas is not a good action. Loud music can increase noise levels, disrupt sleep, and cause agitation and anxiety for clients. The nurse should keep the noise level low and provide earplugs or headphones for clients who want to listen to music.
Choice B reason: Assigning different nurses to provide care for clients each day is not a good action. Different nurses may have different styles, routines, and expectations, which can confuse and frustrate clients. The nurse should maintain consistency and continuity of care by assigning the same nurses to the same clients as much as possible.
Choice C reason: While offering some choices can empower clients and reduce stress, too many choices might overwhelm them, particularly in an acute care setting. The key is to provide a balance of autonomy while not overwhelming the client.
Choice D reason: Limiting the number of visitors can help create a quieter, more controlled environment, reducing overstimulation and stress for clients. This can be particularly important in an acute care setting where rest and a calm environment are crucial for recovery.
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