A nurse is teaching a class at a local senior center regarding safety in the home. A client states, "I am afraid of falling because I live alone and have no one to help me." Which of the following statements should the nurse make?

"You can obtain a personal response system that will be activated if you fall."

"You should contact a family member once a week to keep in touch."

"You can have an unlicensed assistive personnel (UAP) come to your house daily to stay with you."

"You need to move to a skilled nursing facility where they can prevent falls."

Answer and Explanation

The Correct Answer is A

Rationale:
A. "You can obtain a personal response system that will be activated if you fall.": A personal emergency response system allows the client to summon help immediately after a fall, promoting independence and safety for individuals living alone.

B. "You should contact a family member once a week to keep in touch.": Weekly contact provides emotional support but does not ensure timely assistance in the event of a fall. Regular communication is helpful, yet it does not directly reduce fall risk or guarantee safety if an emergency occurs.

C. "You can have an unlicensed assistive personnel (UAP) come to your house daily to stay with you.": Having a UAP visit daily may not be realistic or necessary, especially for independent seniors. This does not provide continuous supervision or an immediate response in case of a fall occurring outside scheduled visits.

D. "You need to move to a skilled nursing facility where they can prevent falls.": Suggesting relocation is premature and disregards the client’s desire for independence. Fall prevention strategies and assistive technology should be explored before recommending institutional care.

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Correct Answer is A

Explanation

Rationale:
A. The client takes multiple steps while holding the walker: Taking several steps while holding the walker increases the risk of imbalance and falls. The correct technique is to move the walker forward one step length, ensure all four legs are stable on the ground, and then take a single step toward it before moving the other leg.

B. The client lifts the walker as it is moved forward: The walker should be lifted slightly and placed firmly on the ground to ensure stability with each step. Sliding the walker instead of lifting it can cause uneven movement or tipping, especially on rough surfaces, making lifting the correct method.

C. The client advances the walker and takes a step towards it: This is the proper technique for safe use. The client should advance the walker first, then step forward with the weaker leg, followed by the stronger leg, maintaining balance and even weight distribution.

D. The client grasps the walker by the hand grips on the upper bars: Proper hand placement on the upper hand grips ensures stability and correct posture during ambulation. Holding the walker anywhere else can cause poor control, imbalance, or wrist strain.

A. Advise the adolescent to place the newborn for adoption. B. Refer the adolescent to a local mental health clinic. C. Contact the adolescent's parent for assistance. D. Assist the adolescent in applying for Medicaid.

Correct Answer is D

Explanation

Rationale:
A. Advise the adolescent to place the newborn for adoption: Suggesting adoption may be perceived as judgmental and does not address the adolescent’s immediate concern about accessing resources and caring for the baby.

B. Refer the adolescent to a local mental health clinic: While emotional support can be beneficial, referral to mental health services alone does not address practical concerns about affording and caring for the baby. Immediate assistance with resources is a priority.

C. Contact the adolescent's parent for assistance: Confidentiality and the adolescent’s autonomy must be respected unless there is a safety concern. The nurse should not contact parents without the adolescent’s consent.

D. Assist the adolescent in applying for Medicaid: Helping the adolescent apply for Medicaid directly addresses her concerns about affording prenatal care and infant needs. This action provides practical support, empowers her to access healthcare and resources, and promotes positive maternal and fetal outcomes.

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A nurse is teaching a class at a local senior center regarding safety in the home. A client states, "I am afraid of falling because I live alone and have no one to help me." Which of the following statements should the nurse make?

Nursing Test Bank

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Explanation

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Correct Answer is D

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