After assessing the older client in his bed, the nurse determines that he is at high risk for falls. The nurse leaves the room to get a fall risk sign and returns to find him on the floor pleading for help. Which of the following was the most important intervention the nurse should have implemented to prevent this event?
Provide a urinal and drinking water.
Call for someone to bring the sign.
Instruct the client to use call bell for help.
Ensure he can reach his personal items
The Correct Answer is C
A. Provide a urinal and drinking water.
Explanation: While providing a urinal and drinking water is important for the client's comfort and hydration, it may not directly address the risk of falls in this situation.
B. Call for someone to bring the sign.
Explanation: Bringing a fall risk sign is a secondary measure and not as immediate as instructing the client to use the call bell. The priority is to ensure the client's safety by addressing the need for assistance promptly.
C. Instruct the client to use the call bell for help.
Explanation: Instructing the client to use the call bell for help is a crucial intervention to ensure that the client can request assistance when needed. Promptly responding to the call bell allows healthcare providers to assist the client with activities such as getting out of bed, using the bathroom, or reaching personal items without the risk of falls. Educating and encouraging clients to use the call bell empowers them to seek assistance and promotes their safety.
D. Ensure he can reach his personal items.
Explanation: Ensuring the client can reach personal items is part of providing a comfortable environment but may not prevent falls. The critical factor in fall prevention is promoting communication and the ability to request assistance in a timely manner.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B","C","E"]
Explanation
A. Women have significantly higher mortality rates from hip fractures than do men.
Explanation: This statement is generally true. Women, particularly older women, tend to have higher mortality rates associated with hip fractures compared to men. This is partly because women are more prone to osteoporosis, a condition that increases the risk of fractures.
B. Hip fractures are associated with very high morbidity and mortality.
Explanation: This statement is generally true. Hip fractures can have significant consequences, including increased morbidity and mortality. Complications, such as infections, immobility-related issues, and other medical conditions, can contribute to the overall impact on health.
C. Hip fractures are a leading cause of hospitalization for older people.
Explanation: This statement is generally true. Hip fractures are a common reason for hospitalization among older adults. The severity of the injury often requires medical intervention, surgery, and rehabilitation.
D. Nearly all older patients who sustain a hip fracture will regain prefracture mobility status within 1 year.
Explanation: This statement is not accurate. While many older patients can regain some mobility with appropriate rehabilitation, not all will regain their prefracture mobility status. The extent of recovery varies among individuals and depends on factors such as overall health, comorbidities, and the severity of the fracture.
E. The major cause of hip fractures is falls.
Explanation: This statement is accurate. Falls are a major cause of hip fractures in older adults. Understanding and addressing factors contributing to falls are essential in preventing hip fractures.
Correct Answer is ["A","C","D","F"]
Explanation
A. Has a history of alcohol abuse
Explanation: Alcohol can contribute to hypothermia as it causes vasodilation, leading to heat loss. It can impair the body's ability to regulate temperature.
B. Bathes three to four times a week
Explanation: While personal hygiene is important, the frequency of bathing alone may not be a direct risk factor for hypothermia. The overall environmental temperature and the individual's ability to regulate their body temperature are more critical considerations.
C. Has a history of diabetes mellitus
Explanation: Diabetes mellitus can increase the risk of hypothermia as it may affect circulation and peripheral nerve function. Impaired sensation and reduced blood flow can contribute to difficulty in maintaining body temperature.
D. Becomes diaphoretic on warm days
Explanation: Excessive sweating (diaphoresis) can contribute to the risk of hypothermia, as it leads to moisture loss from the skin, making it more challenging for the body to maintain a stable temperature.
E. Is prescribed antidepressant
Explanation: While certain medications, including some antidepressants, can affect thermoregulation, the prescription of an antidepressant alone does not necessarily indicate an increased risk of hypothermia. It is essential to consider the specific medication and its potential side effects.
F. Has a history of a cerebrovascular accident (CVA)
Explanation: Individuals with a history of a cerebrovascular accident may have impaired thermoregulation due to damage to the central nervous system. This can increase susceptibility to temperature extremes.
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