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 D

Explanation

A. "I will keep my walker at the end of my bed":

While keeping the walker at the end of the bed may be convenient, it is not a safety measure in itself. It's important for the client to use the walker as needed for support and stability, especially during ambulation.

B. "I will place an area rug at the entry of my bathroom":

Placing area rugs can be a fall hazard, as they may cause tripping. It is generally recommended to have non-slip surfaces, especially in areas prone to moisture like the bathroom.

C. "I will keep the fluorescent ceiling light on in my room at night":

While having adequate lighting is important for preventing falls, leaving a fluorescent ceiling light on all night may not be necessary. Using night lights or low-intensity lighting may be more appropriate to prevent disruption of sleep.

D. "I will place a bath seat in my shower to use when I bathe":

This is the correct statement. Using a bath seat in the shower provides stability and reduces the risk of slipping and falling while bathing. It is a proactive measure to enhance safety in the bathroom.

A. A client who has had prolonged diarrhea B. A client who has lactose intolerance C. A client who has had radiation therapy for head and neck cancer D. A client who has had a stroke E. A client who is 4 hr postoperative following a leg amputation under general anesthesia

Correct Answer is ["C","D","E"]

Explanation

A. A client who has had prolonged diarrhea:

Prolonged diarrhea is not typically associated with an increased risk of aspiration during eating.

B. A client who has lactose intolerance:

Lactose intolerance primarily affects the ability to digest lactose-containing foods and does not directly increase the risk of aspiration.

C. A client who has had radiation therapy for head and neck cancer:

Radiation therapy to the head and neck can cause damage to the structures involved in swallowing, increasing the risk of aspiration.

D. A client who has had a stroke:

Stroke can affect the coordination of swallowing muscles, leading to dysphagia (difficulty swallowing) and an increased risk of aspiration.

E. A client who is 4 hr postoperative following a leg amputation under general anesthesia:

Postoperative clients under general anesthesia may experience impaired protective airway reflexes, making them prone to aspiration. It's important to monitor these clients closely during the initial recovery period.

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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?

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Correct Answer is D

Explanation

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Correct Answer is ["C","D","E"]

Explanation

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