The client has been admitted and placed on fall precautions. The nurse explains to the patient that interventions for the precautions include: (Select All that Apply)

Placing a high risk for falls armband on the patient

Checking on the patient once a shift

Keep the bed in the lowest position

Placing all four side rails in the "up" position

Maintain call light within reach of the patient

Answer and Explanation

Correct Answer : A,C,E

A. Placing a high risk for falls armband on the patient: An armband alerts all healthcare providers to the patient's fall risk, helping to ensure appropriate precautions are taken.
B. Checking on the patient once a shift: This is not sufficient; patients on fall precautions should be checked more frequently, such as every hour or according to the facility's protocol, to ensure their safety.
C. Keep the bed in the lowest position: Keeping the bed at its lowest position reduces the risk of injury from falls and helps ensure the patient can easily get in and out of bed.
D. Placing all four side rails in the "up" position: Using all four side rails is not recommended as it can increase the risk of entrapment and may not be effective in preventing falls. Side rails should be used appropriately and in accordance with safety protocols.
E. Maintain call light within reach of the patient: Ensuring the call light is within reach helps the patient call for assistance if needed, which can help prevent falls.

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Correct Answer is D

Explanation

A. "Advance the cane 12 inches forward when walking." Advancing the cane 12 inches forward is not practical; the cane should be moved in a manner that aligns with the client's steps for better balance and support. The movement of the cane should be synchronized with the client's stride rather than a fixed distance.
B. "Keep the cane at the same level as the affected leg when climbing stairs." When climbing stairs, the cane should be held on the side of the unaffected leg to provide optimal support and balance. Keeping the cane level with the affected leg is incorrect and does not provide adequate support.
C. "Hold the cane on the side of your affected leg when walking." The cane should be held on the side opposite the affected leg to provide better stability and support. Holding the cane on the affected side would not offer the necessary support for effective ambulation.
D. "Move your unaffected leg before your affected leg when walking." This is the correct technique as it ensures better balance and stability. Moving the unaffected leg first while using the cane allows for a more secure and coordinated gait, reducing the risk of falls.

A. Lanugo B. Cold extremities C. Hypotension D. Tooth erosion E. Diarrhea

Correct Answer is ["A","B","C"]

Explanation

A. Lanugo: Lanugo is fine, soft hair that often grows on the body as a response to extreme weight loss and decreased body fat, which is common in anorexia nervosa.
B. Cold extremities: Due to the significant reduction in body fat and poor circulation associated with anorexia nervosa, clients often experience cold extremities.
C. Hypotension: Low blood pressure is frequently observed in individuals with anorexia nervosa due to dehydration, electrolyte imbalances, and overall malnutrition.
D. Tooth erosion: This finding is more commonly associated with bulimia nervosa, where frequent vomiting leads to acid erosion of the teeth, rather than anorexia nervosa.
E. Diarrhea: This is not typically associated with anorexia nervosa; clients may experience constipation more frequently due to reduced food intake and low fiber consumption.

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The client has been admitted and placed on fall precautions. The nurse explains to the patient that interventions for the precautions include: (Select All that Apply)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is teaching a client about using a cane for ambulation. Which of the following statements should the nurse make?

Correct Answer is D

Explanation

A nurse is collecting data from a client who has anorexia nervosa. Which of the following findings should the nurse expect? (Select all that apply.)

Correct Answer is ["A","B","C"]

Explanation

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