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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Free Nursing Study Resources

Correct Answer is ["A","D","E"]

Explanation

Rationale:
A. "Perform Kegel exercises several times daily.": Kegel exercises strengthen pelvic floor muscles, improving bladder control and reducing stress incontinence episodes. Regular practice is essential for effectiveness.

B. "Take prescribed diuretics no later than 2000.": Limiting evening diuretic use helps reduce nighttime incontinence but does not address stress incontinence, which is triggered by increased intra-abdominal pressure, not fluid timing.

C. "Maintain a daily fluid intake of 1,000 to 1,200 mL/day.": Restricting fluids excessively can lead to concentrated urine and urinary tract irritation. Adequate hydration is important; fluid restriction is not recommended for stress incontinence.

D. "Attempt to void every 2 hours.": Scheduled voiding helps prevent bladder overfilling, reducing leakage episodes and improving bladder control. This is an effective behavioral strategy.

E. "Maintain optimal body weight for height.": Excess weight increases intra-abdominal pressure, which can worsen stress incontinence. Maintaining a healthy weight helps reduce strain on pelvic floor muscles.

A. Warm blood products prior to administration. B. Establish a patent oral airway. C. Assign the client a score on the Glasgow Coma Scale. D. Remove the client's clothing.

Correct Answer is B

Explanation

Rationale:
A. Warm blood products prior to administration: While warming blood can prevent hypothermia during transfusion, ensuring airway patency takes priority in a trauma situation to maintain oxygenation and prevent respiratory compromise.

B. Establish a patent oral airway: Airway management is the first step in the ABCs (Airway, Breathing, Circulation) of emergency care. Securing a patent airway ensures oxygen delivery to vital organs, which is critical in a client with multiple traumatic injuries.

C. Assign the client a score on the Glasgow Coma Scale: Assessing neurological status is important, but it is secondary to establishing airway patency. A GCS score cannot help if the client is not oxygenating adequately.

D. Remove the client's clothing: Removing clothing allows a thorough assessment, but it does not take priority over securing the airway, which is essential to prevent hypoxia.

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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?

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Correct Answer is ["A","D","E"]

Explanation

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Correct Answer is B

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