As a nurse prepares an older adult client for bed on the first night of her hospital stay, the client says, "I am afraid that I may fall getting to the bathroom during the night. I tend to get a bit disoriented in new surroundings." Which of the following actions should the nurse take?

Offer to request a prescription for an indwelling urinary catheter.

Keep a night light on in the client's room.

Put the side rails up and tell the client to call for assistance to the bathroom.

Limit the client's fluid intake in the evening.

Answer and Explanation

The Correct Answer is B

A. Offer to request a prescription for an indwelling urinary catheter.

Indwelling urinary catheters come with their own set of risks and complications. It is generally not recommended to use them solely for the purpose of preventing falls unless there are other medical indications for their use. Catheters increase the risk of infection and other complications, and their use should be based on clear medical necessity.

B. Keep a night light on in the client's room.

This option directly addresses the client's concern about falling during the night. Providing a night light in the room helps to alleviate disorientation, making it safer for the client to navigate to the bathroom. It is a practical and non-invasive intervention.

C. Put the side rails up and tell the client to call for assistance to the bathroom.

While using side rails can be a fall prevention measure, it's important to consider that they are not without risks. Side rails can lead to entrapment or injury if not used appropriately. In addition, telling the client to call for assistance is good advice, but relying solely on this instruction may not address the immediate concern of disorientation in new surroundings.

D. Limit the client's fluid intake in the evening.

While limiting fluid intake in the evening might reduce the frequency of bathroom trips, it is not the most appropriate response to the client's concern. Dehydration can lead to other health issues and should not be used as the primary strategy for fall prevention.

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Correct Answer is B

Explanation

A. Palliative care focuses on providing comfort and relief from symptoms for individuals with serious illnesses, often those with life-limiting conditions. Respite care is not specifically designed for palliative care but can complement it by offering temporary relief to caregivers.

B. Respite care is a form of temporary care that allows caregivers a break or time off from their responsibilities. It is intended to provide short-term relief and support for family members or caregivers who are taking care of individuals with chronic illnesses, disabilities, or age-related conditions.

C. Restorative care involves interventions and services aimed at improving an individual's functional abilities and promoting independence. Respite care is not primarily focused on restorative care but rather on giving caregivers a temporary break.

D. Pain management is a specialized area of care that focuses on assessing and treating pain. Respite care, while it may involve managing symptoms during the temporary care period, is not specifically designed for pain management.

A. It is not permissible because the provider should disclose laboratory results or findings to a client. B. It is permissible because the client's sibling made the request. C. It is permissible because the sibling has paid for the service. D. It is not permissible because there is no nurse-client relationship between the sibling and nurse.

Correct Answer is D

Explanation

A. It is not permissible because the provider should disclose laboratory results or findings to a client:

While it is true that the provider should disclose laboratory results or findings to the client, the nurse, in this case, should not be accessing the information on behalf of the sibling without proper authorization.

B. It is permissible because the client's sibling made the request:

Even if the sibling made the request, accessing a client's health information without proper authorization is a violation of privacy and confidentiality.

C. It is permissible because the sibling has paid for the service:

Payment for services does not automatically grant access to health information. Protected health information (PHI) is subject to privacy laws, and access should be granted only to those authorized to receive it.

D. It is not permissible because there is no nurse-client relationship between the sibling and nurse:

This is the correct explanation. The nurse should not access a client's health information, even if it is a family member, without proper authorization. The absence of a nurse-client relationship with the sibling does not justify accessing the client's health information.

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As a nurse prepares an older adult client for bed on the first night of her hospital stay, the client says, "I am afraid that I may fall getting to the bathroom during the night. I tend to get a bit disoriented in new surroundings." Which of the following actions should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is discussing respite care with the caregiver of an older adult client. When the caregiver asks about the purpose of a respite care program, the nurse should reply that it provides which of the following services?

Correct Answer is B

Explanation

A nurse's sibling had a diagnostic test at the nurse's facility. The sibling asks the nurse to look up the result in the computer. The nurse should identify which of the following as the reason for her decision about her sibling's request?

Correct Answer is D

Explanation

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