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 A

Explanation

A.Providing tissues is a helpful measure for clients to use when they need to cough or sneeze. It promotes good hygiene by allowing the client to dispose of respiratory secretions properly. However, this choice does not address the immediate concern of how the client is currently coughing and the potential for spreading infection.
B.Assisting the client with a gown change may be necessary if their current gown is soiled. However, this action does not directly address the infection control issue or the client’s method of coughing. Changing the gown is secondary to addressing proper coughing techniques and infection control.
C.Teaching clients to cover their mouth with their hands is not ideal, as it can spread germs if the hands are not washed immediately afterward. Instead, clients should be taught to cough into a tissue or their elbow (not the sleeve) to minimize the spread of germs. This is a crucial component of infection control and helps reduce the risk of transmission.
D.Providing face masks for staff is an important measure in infection control, especially if the client has a respiratory illness. However, it does not address the client's current coughing technique or teach the client how to prevent the spread of infection through their own actions.

A. Notify the healthcare provider of the client's concerns. B. Ask an unlicensed assistive personnel to stay with the client. C. Obtain a bedside commode for the client to use. D. Place the bedpan within the reach of the client.

Correct Answer is C

Explanation

A. While notifying the healthcare provider may be necessary in some cases, it's not the most immediate or appropriate action in this situation. The nurse can address the client's concerns directly by providing a bedside commode.
B. While having a UAP available for assistance can be helpful, providing a bedside commode is a more practical and efficient solution.
C. A bedside commode can help prevent accidents and spills, which can be embarrassing and contribute to a negative experience. Offering a bedside commode demonstrates respect for the client's concerns and preferences, which can help to build trust and improve the overall care experience.
D. A bedpan may not be as comfortable or convenient for the client as a bedside commode, especially if they have mobility limitations.

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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

When entering a client's room, the nurse observes the client holding up an arm and coughing non-productively into the upper sleeve. Which action should the nurse take?

Correct Answer is A

Explanation

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Correct Answer is C

Explanation

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