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 B
Explanation
Choice A reason: Client instructed on self-care needs is not a specific or accurate documentation. The nurse should include the details of the instruction, such as the topics covered, the teaching methods used, the client's response, and the evaluation of learning.
Choice B reason: Oral temperature elevated at 0800 is a specific and accurate documentation. The nurse should include the vital signs and any abnormal findings, such as fever, in the client's health record. The nurse should also report the elevation to the provider and monitor the client for signs of infection.
Choice C reason: Episiotomy approximated, 3 cm (1.18 in) in length is not a specific or accurate documentation. The nurse should include the type, location, and degree of the episiotomy, as well as the condition of the wound, the presence of edema, erythema, or drainage, and the interventions performed.
Choice D reason: Client drank adequate amounts of fluid with meals is not a specific or accurate documentation. The nurse should include the exact amount and type of fluid intake, as well as the output, in the client's health record. The nurse should also assess the client for signs of dehydration or fluid overload.
Correct Answer is A
Explanation
Choice A reason: Receiving emotional support during the mother’s illness is a sign of understanding the teaching. Palliative care is a holistic approach that aims to improve the quality of life of clients and their families who are facing life-threatening illnesses. It provides physical, psychological, social, and spiritual support to address their needs and preferences.
Choice B reason: Providing resuscitation to the mother if necessary is a sign of misunderstanding the teaching. Palliative care focuses on relieving symptoms and suffering, not curing the illness or prolonging life. It respects the client’s wishes and goals of care, which may include a do-not-resuscitate (DNR) order or an advance directive.
Choice C reason: Not discussing the illness in the presence of the mother is a sign of misunderstanding the teaching. Palliative care encourages open and honest communication between the client and the family, as well as the health care team. It helps the client and the family cope with the illness, express their emotions and concerns, and make informed decisions.
Choice D reason: Not allowing the mother’s spiritual advisor to visit during this time is a sign of misunderstanding the teaching. Palliative care recognizes the importance of spirituality and religion for some clients and their families. It supports the client’s right to practice their faith and receive spiritual guidance and comfort from their chosen source.
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