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.
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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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Move any clients in the immediate vicinity.
This is a reasonable next step, ensuring the safety of clients in close proximity to the potentially hazardous situation.
B. Close the fire doors on the unit.
Closing fire doors is important for containing the spread of smoke and fire, but it may be a secondary action after alerting others to the emergency using the fire alarm.
C. Use a fire extinguisher on the outlet.
While fire extinguishers can be useful in certain situations, using one on an electrical fire can be dangerous. It's generally recommended to leave firefighting to trained personnel and focus on evacuation and alerting others.
D. Activate the fire alarm.
Activating the fire alarm is the priority because it alerts everyone in the facility to the potential danger, ensuring a prompt and coordinated response. It initiates the facility's fire response plan and helps in the evacuation of patients if necessary.
Correct Answer is B
Explanation
A. Concurrent treatment for GERD:
This is not typically a contraindication for hormone replacement therapy (HRT). GERD treatment is not directly related to the decision to use HRT.
B. History of breast cancer:
This is a contraindication for HRT. Estrogen replacement therapy has been associated with an increased risk of breast cancer. Therefore, individuals with a history of breast cancer are generally advised against using HRT.
C. History of dermatitis:
A history of dermatitis is not a contraindication for HRT. However, the decision to use HRT should be made based on a comprehensive assessment of the client's overall health and risk factors.
D. Multiple hospitalizations for COPD:
While COPD itself is not a contraindication for HRT, decisions about HRT should consider the individual's overall health status and potential risks. Factors such as smoking history and respiratory function may be considered in the assessment.
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