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

Answer and Explanation

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.

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Correct Answer is ["B","C","D","E"]

Explanation

A. Two servings of deep-colored fruit.

While fruits are recommended, the "deep-colored" specification is not a specific focus in the MyPlate for Older Adults.

B. Six or more servings of fortified, enriched, or whole grain foods.

Correct. Whole grains are an important source of fiber, vitamins, and minerals.

C. Three or more servings of low-fat or nonfat dairy products.

Correct. Dairy products provide calcium and vitamin D, important for bone health.

D. Three 8-ounce glasses of water.

Correct. Staying hydrated is crucial for overall health, especially for older adults.

E. Four or more servings of high-quality protein.

Correct. Protein is essential for muscle maintenance and repair. Sources of high-quality protein include lean meats, poultry, fish, eggs, dairy, and plant-based protein sources.

F. One or two servings of brightly colored vegetables.

While vegetables are recommended, the "brightly colored" specification is not a specific focus in the MyPlate for Older Adults.

A. Use of resistance bands B. Stretching C. Tat chi D. Yoga E. ROM activities

Correct Answer is ["C","D","E"]

Explanation

A. Use of resistance bands
Explanation: Resistance band exercises can improve strength and flexibility, but they may not specifically address balance as directly as Tai Chi or certain yoga poses.

B. Stretching
Explanation: Stretching exercises contribute to flexibility and can be part of a well-rounded exercise routine. While they can be beneficial, other exercises like Tai Chi and yoga may have a more specific focus on balance improvement.

C. Tai Chi
Explanation: Tai Chi is a low-impact exercise that emphasizes slow, controlled movements, weight shifting, and mindfulness. It has been shown to improve balance and reduce the risk of falls, making it suitable for individuals at high risk.

D. Yoga
Explanation: Yoga incorporates balance, flexibility, and strength exercises. Certain yoga poses can help improve balance and stability, making it beneficial for individuals at risk for falls.

E. Range of Motion (ROM) activities
Explanation: Range of motion activities helps maintain joint flexibility and can contribute to improved balance. Encouraging the client to perform gentle range of motion exercises can be beneficial.

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Naxlex Comprehensive Predictor Exams

Which recommendations for daily food intake is correct for older adults according to the MyPlate for Older Adults? (Select all that apply.)

Correct Answer is ["B","C","D","E"]

Explanation

The nurse should encourage which of the following exercise(s) to assist with balance for a client who is at high risk for falls? (Select all that apply.

Correct Answer is ["C","D","E"]

Explanation

A 79-year-old client resides independently in the community. The visiting home health nurse finds that despite it being 90°F outside, the windows are closed and the client is wearing a sweater. The nurse initially recognizes that this behavior may be related to what?

Which of the following is a true statement about elimination in older adults?

Hypothermia is a medical emergency defined as a core temperature less than 95°F. Which of the following tips to prevent hypothermia should you tell your elderly client? (Select all that apply.)

What are the benefits associated with telehealth technology? (Select all that apply.)

The health care provider has not ordered the use of a restraint for an alert patient at high risk for falling. The nurse should implement which side rail use?

Which of the following is a true statement about nutrition for older adults?

A health care provider asks the nurse about an older adult client's durable power of attorney (POA) because consent is needed for a medically necessary invasive procedure. The client has end-stage disease, is intubated, and is on mechanical ventilation. Which steps should the nurse implement?

An older adult who is on bed rest after surgery is prescribed morphine for pain. Which of the following is the nurse's priority for preventive care?