The nurse assesses an older adult client's ability to perform activities of daily living (ADLs). When observing the client ambulate, the nurse notes that the client's posture is upright, and the gait is smooth and steady. Which action should the nurse take next?

Initiate a fall risk protocol for the client.

Teach the client to shorten the stride to prevent falls.

Determine the client's activity tolerance.

Record the client's ability to perform ADLS safely.

Answer and Explanation

The Correct Answer is C

A. Initiate a fall risk protocol for the client:

Initiating a fall risk protocol may be premature based solely on observations of an upright posture and a smooth, steady gait. While falls are a significant concern in older adults, these observations suggest that the client currently exhibits good balance and mobility, which may not warrant immediate initiation of a fall risk protocol. Fall risk assessments typically involve a comprehensive evaluation of multiple factors beyond posture and gait, such as medical history, medications, cognitive status, and environmental factors.

B. Teach the client to shorten the stride to prevent falls:

Teaching the client to shorten their stride to prevent falls may not be necessary based on the observed smooth and steady gait. Shortening the stride is often recommended for individuals who exhibit signs of imbalance or instability during walking. However, in this scenario, the client demonstrates a smooth and steady gait, suggesting that their current gait pattern is effective and does not pose an immediate risk of falling.

C. Determine the client's activity tolerance:

Assessing the client's activity tolerance is an appropriate next step in the nursing process. While the observed upright posture and smooth, steady gait are positive indicators of mobility, understanding the client's overall activity tolerance provides valuable insight into their functional capacity and ability to perform activities of daily living safely. This assessment helps tailor care interventions to meet the client's individual needs and promotes optimal independence and quality of life.

D. Record the client's ability to perform ADLs safely:

Documenting the client's ability to perform activities of daily living (ADLs) safely is an essential component of nursing assessment and documentation. However, it may not be the most immediate action to take following the observation of an upright posture and smooth, steady gait. While documenting findings is important for maintaining accurate records and facilitating communication among healthcare team members, further assessment of the client's activity tolerance would provide additional context for documenting their functional status accurately.

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Correct Answer is B

Explanation

A. Begin the collection the next day:

This option would delay the start of the 24-hour urine collection unnecessarily. Since the client has already begun voiding, it's appropriate to start the collection process with the next void.

B. Start collecting the specimen with the next void:

Since the client has already provided a urine sample, the nurse should discard this initial void and begin the 24-hour collection process with the next void. This ensures that the entire 24-hour period is captured for accurate measurement of creatinine clearance.

C. Observe the sample for sediment:

While observing the sample for sediment may be part of the assessment process, it is not the priority in this situation. The focus should be on initiating the 24-hour urine collection process correctly.

D. Empty the sample into the 24-hour container:

The initial void should not be emptied into the 24-hour container, as this would inaccurately include urine that was not collected over the entire 24-hour period. It's important to start the collection process fresh with the next void to ensure accurate results for creatinine clearance measurement.

A. Drink a mixture of warm water, whiskey, and honey at bedtime. B. Ask the healthcare provider for a mild sedative for bedtime. C. Avoid drinking caffeinated beverages late in the day. D. Take an afternoon nap to make up for missed sleep. E. Establish a regular time for going to bed and getting up.

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

Explanation

A. Drink a mixture of warm water, whiskey, and honey at bedtime:

This suggestion is not appropriate as alcohol consumption close to bedtime can disrupt sleep patterns and exacerbate sleep problems. Additionally, alcohol can interact with medications and pose risks to health.

B. Ask the healthcare provider for a mild sedative for bedtime:

While medication may be prescribed for sleep disturbances in some cases, it should not be the first line of treatment, especially in older adults. Sedatives can have adverse effects and may lead to dependency if used long-term. Non-pharmacological interventions should be tried first.

C. Avoid drinking caffeinated beverages late in the day:

This is an appropriate suggestion. Caffeine is a stimulant that can interfere with sleep, so avoiding caffeinated beverages late in the day can help improve sleep quality.

D. Take an afternoon nap to make up for missed sleep:

While napping may be beneficial for some individuals, particularly if they are sleep deprived, it can worsen sleep difficulties in others, especially if taken late in the day. For individuals with insomnia or frequent nighttime awakenings, avoiding naps or limiting them to earlier in the day may be helpful.

E. Establish a regular time for going to bed and getting up:

This is an appropriate suggestion. Establishing a consistent sleep schedule helps regulate the body's internal clock and promotes better sleep quality. Going to bed and waking up at the same time each day, even on weekends, can help synchronize sleep-wake cycles and improve overall sleep patterns.

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The nurse assesses an older adult client's ability to perform activities of daily living (ADLs). When observing the client ambulate, the nurse notes that the client's posture is upright, and the gait is smooth and steady. Which action should the nurse take next?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The healthcare provider prescribes a 24 hour urine specimen to be collected for creatinine clearance. The client is eager to go home and tells the nurse that the first sample was put in the urinal 2 hours ago. Which action should the nurse implement?

Correct Answer is B

Explanation

An older adult female client tells the clinic nurse about frequently awakening during the night and not being able to go back to sleep. What action(s) should the nurse suggest to the client to help improve sleep? Select all that apply.

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

Explanation

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