An older adult is brought to the clinic by the oldest adult child who found the client lying on the floor at home conscious, but unable to get up by themself. The client is unable to recall what happened. Which action should the nurse take first?

Gather a history from adult child about circumstances of previous falls.

Inform the adult child that fall prevention is a priority for older adults.

Ask the adult child to remain with the client during the examination.

Encourage the adult child to report the incident to other siblings.

Answer and Explanation

The Correct Answer is A

A.   Understanding the circumstances of previous falls can help identify any risk factors that may have contributed to the current fall. This information can be used to develop a plan to prevent future falls. By gathering information about previous falls, the nurse can develop a more comprehensive plan to address the client's specific needs and reduce the risk of future falls.
B.   While it's important to educate the adult child about fall prevention, gathering information about previous falls is a more immediate priority.
C.   Asking the adult child to remain with the client is appropriate, but it's not the most immediate action needed. Gathering information about previous falls is more important at this stage.
D.   While informing other family members may be important, it's not the most immediate action needed. Gathering information about previous falls is more important at this stage.

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Correct Answer is C

Explanation

A. Morphine is a potent opioid used for pain relief, but it can have side effects, including respiratory depression. While it is important to be aware of and discuss potential side effects, focusing on
respiratory problems might increase the client’s anxiety about using the medication.
B. A PCA pump allows patients to self-administer pain medication within prescribed limits, providing more control over pain management. However, PCA pumps are typically used in hospital settings and may not be practical or appropriate for home hospice care.
C. Providing a schedule for around-the-clock analgesic use is a practical and effective approach to pain management. It ensures that the client receives consistent pain relief and helps prevent the pain from becoming unmanageable.
D. Teaching the family to evaluate the effectiveness of analgesics is important for ongoing pain management. This includes recognizing signs of pain relief and potential side effects. However, this action might be more relevant once pain management is underway and requires follow-up, rather than addressing the immediate concern of managing pain effectively from the start.

A. Practices bicep and triceps isometric exercises. B. Progresses to foot touchdown and weight bearing of affected leg. C. Bears body weight on the palms of hands during the crutch gait. D. Inspects crutches to ensure rubber tips are intact.

Correct Answer is C

Explanation

A. While practicing strength-building exercises for the arms, such as isometric exercises for the biceps and triceps, is beneficial for overall crutch use, it does not directly indicate proper crutch walking technique.
B. This choice is not correct for a three-point gait, especially in the case of a broken foot. In a three-point gait, the client should avoid bearing weight on the affected leg, as this gait is used to promote healing of a non-weight-bearing limb.
C. This behavior indicates a correct understanding of crutch walking. In the three-point gait, the client should bear weight on the crutches' handles and not on the armpits, which helps prevent nerve damage and provides better stability.
D. While it is important for safety to ensure that the rubber tips of the crutches are intact and not worn out, this behavior does not directly demonstrate the client’s understanding of the three-point gait technique.

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An older adult is brought to the clinic by the oldest adult child who found the client lying on the floor at home conscious, but unable to get up by themself. The client is unable to recall what happened. Which action should the nurse take first?

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Naxlex Comprehensive Predictor Exams

In-home hospice care is arranged for a client with stage 4 lung cancer. While the palliative care nurse is arranging for discharge, the client verbalizes concerns about pain. Which action should the nurse implement?

Correct Answer is C

Explanation

The nurse is demonstrating three-point gait crutch walking to an older adult man who broke his foot while playing soccer with his grandchildren. Which behavior indicates that the client understands proper crutch walking?

Correct Answer is C

Explanation

A client is admitted to the rehabilitation unit following a cerebrovascular accident (CVA), which resulted in paralysis of the right arm. When the nurse enters the room, the client is struggling to put on a shirt, and curses at the nurse. Which response is best for the nurse to provide?

While cleansing a client's surgical incision, the nurse observes the incision as seen in the picture. How should the nurse document the appearance of the incision?

While inserting an indwelling urinary catheter into a female client, the nurse observes urine flow in the tubing. Which action should be taken next?

Which assessment is most important for the nurse to perform prior to the application of a heating pad?

The nurse is teaching another nurse about the administration of medication using the Z track technique. Which is the primary reason for using a Z track technique to administer a medication?

The nurse assesses an adult client with a partial rebreather mask and notes that the oxygen reservoir bag does not deflate completely during inspiration and the client's respiratory rate is 14 breaths/minute. Which action should the nurse implement?

An elderly woman comes to the clinic because of vaginal bleeding. The healthcare provider finds a vagina tear, which the client reports is likely to have occurred during sexual intercourse. Which content is most important for the nurse to include in this client's teaching plan?