A nurse is preparing to apply a bed alarm for a client who is at risk for falls and attempts to get out of bed without assistance. After explaining the procedure to the client, which of the following actions should the nurse take next?

Instruct the client to use the call light for assistance.

Document the type of alarm used.

Test the alarm and battery of the device.

Apply the sensor pad to the client's bed.

Answer and Explanation

The Correct Answer is C

A. Instruct the client to use the call light for assistance. This is important but should be done after ensuring the alarm is working correctly.
B. Document the type of alarm used. Documentation is necessary but should follow ensuring the device is functioning.
C. Test the alarm and battery of the device. Ensuring the bed alarm and battery are functioning properly is critical to the safety of the client. The alarm needs to be reliable to alert staff if the client attempts to get out of bed.
D. Apply the sensor pad to the client's bed. This step is necessary but should follow testing the alarm and battery to ensure they are functioning.

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Correct Answer is A

Explanation

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.

A. Tingling in the toes B. 1+ dorsalis pedis pulse C. Capillary refill of 3 seconds D. Increased edema of the foot

Correct Answer is D

Explanation

A. Tingling in the toes: Tingling in the toes is not specific to CRPS. It might be a general symptom but is not a classic sign of CRPS.
B. 1+ dorsalis pedis pulse: A weak pulse might indicate reduced circulation but is not specific to CRPS. CRPS is more associated with pain, swelling, and changes in skin color or temperature.
C. Capillary refill of 3 seconds: A capillary refill time of 3 seconds is prolonged and suggests possible circulation issues, but it is not a specific manifestation of CRPS.
D. Increased edema of the foot: Increased edema of the foot is a common manifestation of CRPS. CRPS often presents with localized swelling, along with other symptoms like pain and changes in skin color or temperature.

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A nurse is preparing to apply a bed alarm for a client who is at risk for falls and attempts to get out of bed without assistance. After explaining the procedure to the client, which of the following actions should the nurse take next?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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?

Correct Answer is A

Explanation

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Explanation

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