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 ["B","C","D"]
Explanation
A. Use absorbent incontinent pads.
Explanation: While absorbent incontinent pads are useful for managing incontinence, they do not directly contribute to preventing hypothermia. Maintaining warmth through appropriate clothing and insulation is more relevant to hypothermia prevention.
B. Eat high-protein meals.
Explanation: Consuming high-protein meals is important for maintaining energy and body heat. Protein metabolism produces heat as a byproduct, contributing to overall warmth.
C. Layer clothing and bedclothes.
Explanation: Layering helps trap warmth close to the body, providing insulation. This is an effective strategy to prevent heat loss and maintain body temperature.
D. Use a head covering.
Explanation: A significant amount of heat is lost through the head. Wearing a head covering, such as a hat or a cap, helps to minimize heat loss and maintain body temperature.
E. Use your comfort level to set the thermostat.
Explanation: Relying solely on personal comfort to set the thermostat may not provide adequate protection against hypothermia. It is important to keep indoor temperatures at a level that ensures warmth and minimizes the risk of cold exposure, especially for elderly individuals who may be more susceptible to temperature extremes.
Correct Answer is ["A","B","C","D","E"]
Explanation
A. Use cool or tepid water: Applying cool or tepid water to the body, such as through a cool bath or damp cloth, can help reduce body temperature.
B. Avoid alcohol: Alcohol can contribute to dehydration, which increases the risk of hyperthermia. It's important to encourage the client to avoid alcoholic beverages during hot weather.
C. Minimize exertion: Exertion in high temperatures can lead to an increase in body heat. Advising the elderly client to minimize physical exertion during hot weather helps prevent overheating.
D. Wear cool clothing such as silk or polyester: Light and breathable fabrics, such as silk or polyester, promote better air circulation and help the body stay cool.
E. Drink plenty of fluids: Staying hydrated is crucial in preventing hyperthermia. Encourage the client to drink plenty of fluids, particularly water, to maintain proper hydration levels.
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