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 should contact a family member once a week to keep in touch.
You need to move to a skilled nursing facility where they can prevent falls.
You can have an unlicensed assistive person come to your house daily to stay with you.
Install grab bars and remove loose rugs to reduce your risk of falling.
The Correct Answer is D
Choice A reason: Contacting a family member weekly does not directly address fall prevention for a senior living alone. While social support is valuable, it does not mitigate physical fall risks like environmental hazards. This response fails to provide practical safety measures, making it inadequate for the client’s concern.
Choice B reason: Suggesting a move to a skilled nursing facility is extreme and dismisses the client’s autonomy to remain at home. Many seniors can live safely with modifications like grab bars or assistive devices. This response does not address immediate fall prevention strategies, making it inappropriate and overly restrictive.
Choice C reason: Having an unlicensed assistive person stay daily is impractical and costly for fall prevention. It does not address environmental hazards, the primary cause of falls. Home modifications and assistive devices are more effective and sustainable, making this response less appropriate than environmental safety measures.
Choice D reason: Installing grab bars and removing loose rugs directly reduces fall risks by improving stability and eliminating tripping hazards. These evidence-based modifications are effective for seniors living alone, enhancing safety without compromising independence. This response addresses the client’s fear with practical, actionable solutions, making it correct.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason: Decreased serotonin levels are linked to depression, as serotonin regulates mood in the brain’s limbic system. Antidepressants like SSRIs increase serotonin, alleviating low mood and anhedonia, making this client a prime candidate for therapy to address neurochemical imbalances in depression.
Choice B reason: Decreased cortisol is not directly tied to depression requiring antidepressants. Cortisol dysregulation may occur in stress disorders, but antidepressants target serotonin or norepinephrine, not adrenal function, making this client less suitable for antidepressant therapy based on this imbalance.
Choice C reason: Elevated dopamine is linked to schizophrenia or mania, not depression. Antidepressants target serotonin or norepinephrine, not dopamine. This client may need antipsychotics or mood stabilizers, not antidepressants, as dopamine excess does not indicate depressive pathology requiring such therapy.
Choice D reason: Elevated thyroid levels suggest hyperthyroidism, mimicking anxiety, not depression. Antidepressants are not indicated, as treatment targets thyroid function. Depression may coexist, but thyroid correction is prioritized, making this client unsuitable for primary antidepressant therapy based on this finding.
Correct Answer is B
Explanation
Choice A reason: Administering oxygen is premature without assessing the cause of chest heaviness. While hypoxia may occur in aneurysm rupture, stopping exertion reduces cardiovascular demand first, prioritizing safety in a client with an abdominal aortic aneurysm at risk for rupture.
Choice B reason: Having the client sit down is the priority, as chest heaviness may signal aneurysm instability. Rest reduces aortic wall stress and oxygen demand, preventing rupture or dissection, stabilizing the client for further assessment and intervention in this high-risk condition.
Choice C reason: Checking vital signs is important but secondary to stopping exertion. Chest heaviness suggests potential aneurysm rupture, and continued ambulation risks catastrophe. Sitting the client minimizes cardiovascular stress, allowing subsequent vital sign checks to guide further actions effectively.
Choice D reason: Notifying the provider is critical but not first. Chest heaviness requires immediate cessation of activity to reduce aortic pressure. Sitting stabilizes the client, allowing data collection (e.g., vital signs) before provider notification, ensuring urgent intervention for potential aneurysm complications.
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