A nurse is preparing to assess a client. Which action should the nurse take to check cranial nerve VI?

Choice A Reason:

Age dose of pain medication refers to adjusting the dosage of pain medication based on the client’s age. Elderly clients often have different pharmacokinetics and pharmacodynamics compared to younger individuals, which means they may require lower doses of medication to achieve the same effect. This adjustment helps to prevent overmedication and potential side effects, ensuring safe and effective pain management for elderly clients.

Choice B Reason:

Correct method of administering your own pain medication is important for clients who are capable of self-administering their medication. However, this choice does not directly address the issue of balance deficit and the need for an assistive device. While proper medication administration is crucial, it is not the primary concern in this scenario.

Choice C Reason:

Operator can push the PCA button for you if you are asleep is not an appropriate practice. Patient-controlled analgesia (PCA) is designed to allow clients to self-administer pain medication as needed. Allowing someone else to push the button can lead to overmedication and potential complications. This choice does not address the need for an assistive device for balance deficit.

Choice D Reason:

The pain medication is delivered at your nose is not a standard method of pain medication administration. This choice is incorrect and does not relate to the client’s need for an assistive device for balance deficit. Pain medication is typically administered orally, intravenously, or through other appropriate routes, but not through the nose.

Choice A Reason:

A client who is 3 days postoperative and has a nursing assistant helping him out of bed is at some risk for falls due to recent surgery and potential weakness. However, the presence of a nursing assistant reduces this risk significantly. Postoperative clients are often monitored closely and assisted with mobility to prevent falls.

Choice B Reason:

An adolescent client who has a leg fracture and has been using crutches for the past 2 weeks is at risk for falls due to the use of crutches and limited mobility. However, adolescents generally have better balance and coordination compared to older adults, and they adapt quickly to using mobility aids.

Choice C Reason:

An older adult client who is confused and has urinary frequency is at the greatest risk for falls. Confusion can lead to disorientation and poor judgment, increasing the likelihood of falls. Urinary frequency can cause the client to rush to the bathroom, further increasing fall risk. Older adults also tend to have decreased strength and balance, compounding the risk.

Choice D Reason:

A client with diabetes mellitus who has a leg ulcer is at risk for falls due to potential neuropathy and impaired mobility. However, this risk is generally lower compared to a confused older adult with urinary frequency. The leg ulcer may cause some mobility issues, but it does not typically lead to the same level of disorientation and urgency as urinary frequency.