A nurse is reinforcing home safety instructions for a patient with a history of falls.
Which statement should the nurse identify as an indication that the patient understands the instructions?
“I will place a bath seat in my shower to use when I bathe.”.
“I will keep the fluorescent ceiling light on in my room at night.”.
“I will place an area rug at the entry of my bathroom.”.
“I will keep my walker at the end of my bed.”. .
The Correct Answer is A
Choice A rationale
Placing a bath seat in the shower is a good safety measure for a patient with a history of falls. It allows the patient to sit while bathing, reducing the risk of slipping and falling.
Choice B rationale
Keeping the fluorescent ceiling light on in the room at night can actually increase the risk of falls. It can create shadows and glare that can be disorienting, especially for older adults.
Choice C rationale
Placing an area rug at the entry of the bathroom is not recommended. Rugs can easily become tripping hazards, especially if they’re not secured to the floor.
Choice D rationale
Keeping a walker at the end of the bed can be helpful for some patients, but it’s not the best indication that the patient understands home safety instructions. It’s important that the walker is used correctly and that the patient’s home is arranged to accommodate its use.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale
Rapid respirations that are unusually deep and regular are not indicative of Cheyne-Stokes respirations. Cheyne-Stokes respirations are characterized by periods of apnea followed by gradually increasing then decreasing tidal volumes until another period of apnea.
Choice B rationale
An inability to breathe without dyspnea unless sitting upright is not indicative of Cheyne- Stokes respirations. This is more characteristic of orthopnea, which is commonly seen in conditions like heart failure.
Choice C rationale
Breathing ranging from very deep to very shallow with periods of apnea is indicative of Cheyne-Stokes respirations. This pattern of breathing is often seen in conditions such as heart failure, stroke, or brain damage.
Choice D rationale
Shallow breathing alternating with periods of apnea is not indicative of Cheyne-Stokes respirations. In Cheyne-Stokes respirations, the pattern of breathing includes periods of apnea followed by a gradual increase and then decrease in the depth of respirations.
Correct Answer is B
Explanation
Choice A rationale
Locking the wheels of the bed and the wheelchair is an important safety measure when assisting a client to move from the bed to a wheelchair. However, this action alone is not sufficient. The nurse also needs to ensure the client’s safety during the transfer by using proper body mechanics and providing adequate support.
Choice B rationale
Elevating the bed to a position of comfort for the nurse is the correct action. This helps to ensure that the nurse can maintain proper body mechanics during the transfer, reducing the risk of injury to both the nurse and the client.
Choice C rationale
Getting the help of several staff members to lift the client is not typically necessary when transferring a client with generalized weakness from the bed to a wheelchair. With proper positioning and technique, one nurse can often safely assist the client with this type of transfer.
Choice D rationale
Placing the wheelchair at a 90° angle to the bed is not the recommended position when transferring a client from the bed to a wheelchair. Instead, the wheelchair should be positioned parallel to the bed or at a slight angle.
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