An older adult woman who lives alone talks with the clinic nurse about her fears of falling at home. Which interventions should the nurse suggest? Select all that apply.

Wear an emergency response pendant at home.

Recommend installing grab bars by toilets, bathtub, and shower.

Request that a family member move in with her.

Encourage exercise to improve balance and mobility.

Have the home health nurse assess the home for fall risks.

Answer and Explanation

Correct Answer : A,B,D,E

A.   This device can be used to summon help quickly in case of a fall or other emergency.
B.   Grab bars provide extra support and can help prevent falls in areas where the risk is high.
C.   Request that a family member move in with her might be a solution for some people but it is not always practical or desirable. It's important to consider the client's preferences and independence when making recommendations.
D.   Regular exercise can help strengthen muscles and improve balance, reducing the risk of falls.
E.   A home health nurse can identify potential hazards in the home and make recommendations for modifications to improve safety.

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Correct Answer is C

Explanation

A. This description is more characteristic of a Stage 3 or Stage 4 pressure injury. Stage 3 pressure injuries involve full-thickness skin loss and may expose subcutaneous tissue, and Stage 4 involves extensive damage with possible exposure of muscle, bone, or tendon. Sloughing (a type of necrotic tissue) is not typical of Stage 2 pressure injuries.
B. This description is more indicative of a Stage 1 pressure injury. Stage 1 injuries are characterized by non-blanchable erythema of intact skin, and pain or discomfort in the affected area is common. Stage 1 does not involve the loss of skin integrity, so it would not be the appearance of a Stage 2 injury.
C. This description accurately matches the appearance of a Stage 2 pressure injury. Stage 2 pressure injuries are characterized by partial-thickness loss of skin, which may present as a shallow open ulcer with a red or pink wound bed. It does not extend through the entire thickness of the skin.
D. This description aligns with Stage 3 or Stage 4 pressure injuries, which involve full-thickness skin loss with possible necrotic tissue and deep pockets of infection. These stages involve significant tissue damage beyond what is seen in Stage 2 injuries.

A. Ask the client how often episodes of sun downing are experienced. B. Assist the client with values clarification about end-of-life care options. C. Question the client about the frequency of falls in recent months. D. Request to have the client lie as still as possible for the assessment.

Correct Answer is C

Explanation

A. Sundowning refers to confusion and agitation that typically occurs in the late afternoon or evening in some individuals with dementia or other cognitive impairments. While important for understanding the client’s cognitive and behavioral patterns, this question is more specific to cognitive or behavioral issues rather than directly assessing functional abilities.
B. Values clarification regarding end-of-life care is crucial, especially for advanced planning and ensuring that care aligns with the client’s preferences. However, this is typically part of a different type of discussion and planning, rather than a general functional assessment.
C. Inquiring about recent falls is a relevant component of a functional assessment. Falls can indicate issues with mobility, balance, strength, or cognitive function, all of which are critical for assessing a client's need for nursing home care. Understanding the frequency and circumstances of falls helps in evaluating the client's overall safety and functional status, which is essential for planning appropriate care.
D. Asking the client to lie still is not typically relevant or necessary for a functional assessment, which
generally involves evaluating the client’s ability to perform activities of daily living (ADLs), mobility, and overall function. A functional assessment often involves observing the client’s movement, activities, and responses, which requires them to be active and engaged rather than lying still.

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An older adult woman who lives alone talks with the clinic nurse about her fears of falling at home. Which interventions should the nurse suggest? Select all that apply.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

During the shift change report, the nurse is told that a client has a stage 2 pressure injury. Which ulcer appearance is most likely to be observed?

Correct Answer is C

Explanation

The nurse is performing a functional assessment for a client requiring nursing home care. During the client interview, which action should the nurse implement?

Correct Answer is C

Explanation

The nurse identifies the hospitalized client in which situation as being at highest risk for the development of a healthcare associated infection (HAI)?

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