A nurse is developing a plan of care for an older adult client who has osteoporosis. Which of the following interventions to prevent falls should the nurse include in the plan?

Instruct the client to use the hallway grab bars when walking.

Assist the client to the bathroom every 4 hr.

Administer an antianxiety medication at bedtime.

Monitor the client's activity every 2 hr.

Answer and Explanation

The Correct Answer is A

A. Instruct the client to use the hallway grab bars when walking. This is correct. Using hallway grab bars provides support and stability, helping to prevent falls in clients with osteoporosis.
B. Assist the client to the bathroom every 4 hr. Assisting the client to the bathroom regularly is important, but every 4 hours might not be frequent enough and doesn't directly address fall prevention throughout all activities.
C. Administer an antianxiety medication at bedtime. Antianxiety medications can cause sedation and increase the risk of falls, especially in older adults.
D. Monitor the client's activity every 2 hr. Monitoring the client’s activity is important, but this does not provide specific fall prevention strategies or interventions.

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Correct Answer is A

Explanation

A. Compile a list of the client's current medications to compare with new medications. Medication reconciliation is a key component of The Joint Commission's National Patient Safety Goals. It helps prevent medication errors by ensuring that all medications are reviewed and documented.
B. Label syringes, but not medicine cups or basins, during a procedure. All medications and solutions should be labeled to prevent medication errors, including those in syringes, medicine cups, and basins. Not labeling all items can lead to confusion and errors.
C. Use one client identifier for treatments, care, and services. Using at least two identifiers (e.g., name and date of birth) is recommended to ensure correct patient identification and reduce the risk of errors.
D. Perform a daily assessment of wounds using the Braden scale. The Braden scale is used for assessing pressure ulcer risk, not for daily wound assessment. While regular assessment of wounds is important, the Braden scale is not the correct tool for this purpose.

A. Assist the client to make autonomous decisions about his treatment options. B. Reflect on her own opinion about withholding the diagnosis from him. C. Inform the family that he has a legal right to be informed of his diagnosis. D. Determine the family's reasons for not telling him about his diagnosis.

Correct Answer is D

Explanation

A. Assist the client to make autonomous decisions about his treatment options. Assisting the client to make autonomous decisions is important, but it cannot be done effectively until the client is aware of his diagnosis. This action would follow once the client is informed.
B. Reflect on her own opinion about withholding the diagnosis from him. Reflecting on her own opinion can help the nurse understand her biases but does not directly address the family's request or the client's immediate needs.
C. Inform the family that he has a legal right to be informed of his diagnosis. Informing the family about the client's legal right is essential, but first, the nurse should understand the family's perspective and concerns.
D. Determine the family's reasons for not telling him about his diagnosis. This is correct. Understanding the family's reasons provides context and helps the nurse address their concerns appropriately while advocating for the client’s right to know his diagnosis.

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A nurse is developing a plan of care for an older adult client who has osteoporosis. Which of the following interventions to prevent falls should the nurse include in the plan?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is D

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