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 C
Explanation
A. Semiprivate room.
Explanation: Medicare can cover the cost of a semiprivate room during a qualifying hospital stay or skilled nursing facility stay.
B. Hospice care.
Explanation: Medicare provides coverage for hospice care for individuals with a terminal illness and a life expectancy of six months or less.
C. Custodial care.
Explanation: Custodial care, which involves assistance with activities of daily living (ADLs) such as bathing, dressing, and feeding, is generally not covered by Medicare. Medicare primarily covers medically necessary and skilled care, such as hospital stays, certain nursing home stays, hospice care, and some home health care services. Custodial care, which focuses on assistance with routine personal care, is considered non-medical and is typically not covered by Medicare.
D. Skilled care.
Explanation: Medicare covers skilled care, including services provided by healthcare professionals such as nurses and therapists, when deemed medically necessary. Skilled care is typically required to improve or maintain a person's condition.
Correct Answer is A
Explanation
A. Transportation can be a critical factor in nutritional insufficiency in older adults.
Explanation: Limited access to transportation can be a barrier for older adults in obtaining nutritious food. This can lead to challenges in grocery shopping and accessing fresh, healthy food options. Lack of transportation may contribute to nutritional insufficiency in older individuals.
B. Soul food is a concern primarily for the African-American culture.
Explanation: This statement is not accurate. Dietary concerns and considerations, including those related to health, are not exclusive to any particular culture. Soul food, like any cuisine, can be enjoyed in moderation, but it's important to focus on a balanced and nutritious diet.
C. No government programs promote congregate dining among older adults.
Explanation: This statement is not true. There are government programs, such as the Older Americans Act Nutrition Program, that support congregate dining among older adults. These programs aim to provide nutritious meals to older individuals and foster social interactions by offering group dining opportunities.
D. The older person should be encouraged to practice strict controls on cholesterol intake to ensure protection against heart disease.
Explanation: While monitoring cholesterol intake is important for heart health, the term "strict controls" might not be universally applicable. Recommendations for cholesterol intake can vary based on an individual's overall health status, medical history, and specific dietary needs. It's advisable to consult with a healthcare professional for personalized advice on cholesterol management for older adults.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.
