A nurse is presenting a class about fall prevention to a group of assisted-living residents. Which of the following statements by a resident best indicates an understanding of the teaching?

"I should get a longer cord for my telephone."

"I should place a throw rug over electrical cords."

"It is a good idea to use the handrails in the bathroom."

"I should use chairs without armrests."

Answer and Explanation

The Correct Answer is C

Choice a reason:
Getting a longer cord for the telephone may reduce the risk of tripping over a short cord but could potentially introduce new tripping hazards if not managed properly. It's important to keep cords secured and out of walkways to prevent falls.

Choice b reason:
Placing a throw rug over electrical cords is not advisable as it can create a tripping hazard. Rugs should be secured with non-slip backing and kept away from high-traffic areas to prevent falls.

Choice c reason:
Using handrails in the bathroom is a recommended safety measure to prevent falls. Bathrooms can be slippery, and handrails provide support and stability for residents when moving around in this area.

Choice d reason:
Using chairs without armrests is not a recommended practice for fall prevention. Chairs with armrests can aid residents in safely sitting down and standing up, providing support and reducing the risk of falls.

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Correct Answer is D

Explanation

The correct answer is d) Stage II.
Choice a reason:
Stage IV pressure ulcers are the most severe, with full-thickness skin loss and exposed bone, tendon, or muscle. Signs of stage IV include large-scale tissue loss, possibly including slough or eschar, and may include undermining and tunneling. The scenario described does not indicate such an advanced stage, as there is no mention of exposed deeper tissues or structures.
Choice b reason:
Stage III pressure ulcers involve full-thickness skin loss, potentially affecting subcutaneous tissue but not extending to underlying muscle or bone. The wound may have a crater-like appearance. The described condition does not match stage III, as there is no indication of the ulcer extending into subcutaneous tissue.
Choice c reason:
Stage I pressure ulcers present with intact skin and non-blanchable redness of a localized area usually over a bony prominence. The skin may be painful, firm, soft, warmer, or cooler compared to adjacent tissue. In the given scenario, the skin is not intact, ruling out stage I.
Choice d reason:
Stage II pressure ulcers are characterized by partial-thickness loss of dermis presenting as a shallow open ulcer with a red-pink wound bed, without slough. They may also present as intact or ruptured blisters. The description of the skin condition with erythema, serosanguineous drainage, and a blister-like appearance aligns with a stage II pressure ulcer.

A. The immunization schedule recommended for the client's age. B. The need for regular mammogram screening to identify breast cancer lesions. C. The need for consistent use of seat belts when in a motor vehicle. D. The impact of annual vision examinations on personal health and safety.

Correct Answer is B

Explanation

Choice a reason:
Immunization schedules are typically considered a part of primary prevention. They are intended to prevent diseases before they occur by using vaccines to provide immunity against infections.

Choice b reason:
Regular mammogram screenings are a form of secondary prevention. They are used to detect breast cancer lesions early before symptoms appear, which can lead to more effective treatment and better outcomes.

Choice c reason:
The consistent use of seat belts is a primary prevention strategy. It is a proactive measure to prevent injuries in the event of a motor vehicle accident.

Choice d reason:
Annual vision examinations can be considered part of secondary prevention if they are used to detect vision problems or eye diseases in their early stages. However, they can also be seen as primary prevention because they help maintain and protect eye health before issues arise.

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A nurse is presenting a class about fall prevention to a group of assisted-living residents. Which of the following statements by a resident best indicates an understanding of the teaching?

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Correct Answer is D

Explanation

While conducting the health assessment, the nurse instructs the client about secondary prevention activities. What information did the nurse most likely provide to this client?

Correct Answer is B

Explanation

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