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 D
Explanation
Choice A reason: Informed consent does not prevent a client from refusing the procedure, as they retain the right to withdraw consent at any time before or during the process. This statement is incorrect, as it misrepresents the client’s autonomy and legal rights under informed consent principles.
Choice B reason: The nurse’s role in witnessing consent is to verify the client’s voluntary agreement, not to explain the procedure in detail. The surgeon or provider is responsible for detailed explanations, making this action outside the nurse’s scope in this context and incorrect.
Choice C reason: Explaining risks and benefits is the surgeon’s responsibility, not the nurse’s when witnessing consent. The nurse ensures the client understands and agrees voluntarily but does not provide the explanation, making this an incorrect description of the nurse’s role in the process.
Choice D reason: The client’s voluntary agreement is a core legal requirement of informed consent, which the nurse verifies as a witness. This ensures the client understands the procedure, risks, and benefits and consents without coercion, aligning with ethical and legal standards, making it correct.
Correct Answer is A
Explanation
Choice A reason: Using two identifiers (e.g., name and medical record number) ensures the correct client receives the medication, preventing errors. This aligns with safety protocols, reducing risks of administering drugs to the wrong person. Verification confirms identity before administration, safeguarding against adverse events and ensuring compliance with standards like The Joint Commission.
Choice B reason: Checking the medication label twice is part of the “rights” of administration but is less specific than using two identifiers for client verification. While important, it addresses medication accuracy, not client identity, which is the primary safety concern to prevent errors, making it less critical in this context.
Choice C reason: Administering medication within 3 hours of the scheduled time relates to timing protocols, not the core action of ensuring safe administration. While timely administration is important, verifying client identity is the priority to prevent errors, as incorrect patient identification can lead to severe adverse events, making this less relevant.
Choice D reason: Administering medications to treat a condition to the actual prescriptions is vague and not a standard safety action. The focus is on verifying client identity and medication accuracy, not a general treatment alignment. This statement does not address a specific, actionable step in safe medication administration, making it incorrect.
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