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 D

Explanation

A. While medical diagnoses can influence the type of care a client needs, functional capacity is the most important factor when determining the best living environment.
B. Age and gender can be factors to consider, but they are not as important as functional capacity. For example, an older adult with a high level of functional independence may be able to live independently, even if they are elderly.
C. This is not relevant to the decision of where an older adult client should live.
D. The client's functional capacity is the most important factor to consider when determining the best living environment. If the client requires significant assistance with ADLs, a nursing home or assisted living facility may be the most appropriate option.

A. Tell the client to use larger bags that expand with gas. B. Teach the client how to burp the bag to relieve the gas. C. Ensure that the pin holes are made at the top of the bag. D. Inform the client about bags that have gas release valves.

Correct Answer is D

Explanation

A. Using larger bags might help accommodate the gas more comfortably and reduce the need for making pinholes. However, this solution does not address the immediate issue of gas accumulation and may not be practical for all clients.
B. "Burping" the bag is a recognized technique for managing gas in colostomy bags. It involves opening the end of the bag slightly to release gas, which helps to prevent the bag from ballooning and causing discomfort. This method is effective and safe, as it is specifically designed to manage gas without compromising the integrity of the bag.
C. Making pinholes in the colostomy bag is not a recommended practice. Pinholes can lead to leakage and increase the risk of skin irritation or infection. While ensuring the pinholes are at the top might reduce some complications, it does not solve the fundamental issue and poses a risk to the client's health and hygiene.
D. Colostomy bags equipped with built-in gas release valves are designed specifically to manage gas accumulation safely and effectively. Informing the client about these specialized bags provides a practical solution to the problem of gas buildup and avoids the risks associated with making pinholes.

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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

In assisting the family of an older adult client to determine the best living environment for the client, which factor is most important for the nurse to consider?

Correct Answer is D

Explanation

A client with a colostomy tells the nurse about making small pin holes in the drainage bag to help relieve the gas that collects. Which action should the nurse implement?

Correct Answer is D

Explanation

An older adult client's skin feels warm and the client has a temperature of 101.2° F (38.4° C). The nurse further assesses that the client has a reddened tongue, dry mucous membranes, and inelastic skin turgor. Which serum laboratory value should the nurse monitor most closely?

When establishing a therapeutic environment for an older adult client, which intervention is most important for the nurse to implement?

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A client in the outpatient clinic reports experiencing hard, infrequent stools. Which instruction should the nurse provide this client?

The unlicensed assistive personnel (UAP) tells the nurse that an older client has requested powder applied after a tub bath to relieve itchy dry skin. Which instruction should the nurse provide to the UAP?

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?

When evaluating the effectiveness of a client's nursing care, the nurse first reviews the expected outcomes identified in the plan of care. What action should the nurse take next?

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