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 A

Explanation

A. Provide a back rub at bedtime:

This intervention addresses the client's immediate need for comfort and relaxation without resorting to restrictive measures or medications.

B. Leave the door to the client's room open slightly:

Leaving the door open may not prevent wandering and could potentially lead to safety issues.

C. Apply wrist restraints to prevent wandering:

Restraints should only be used as a last resort and when all other interventions have failed. They pose risks to the client's physical and psychological well-being and should be avoided whenever possible.

D. Administer a PRN sedative prescription:

Sedatives should be used judiciously and only after other non-pharmacological interventions have been attempted. Sedating the client may increase the risk of falls or injury and should not be the first-line intervention for managing sleep disturbances or wandering behavior.

A. Elevate the head of the bed to a 45 degree angle. B. Lift and lock the side rails in place. C. Apply the client's positive airway pressure device. D. Remove dentures or other oral appliance.

Correct Answer is C

Explanation

A. Elevate the head of the bed to a 45-degree angle:

Elevating the head of the bed can help improve airway patency and reduce the risk of airway obstruction in clients with OSA. While this intervention is important, applying the positive airway pressure device (CPAP or BiPAP) takes precedence due to its direct impact on maintaining airway patency and preventing respiratory compromise.

B. Lift and lock the side rails in place:

Ensuring the safety of the client by lifting and locking the side rails is important, but it does not directly address the client's OSA or the potential respiratory depression associated with opioid analgesic administration.

C. Apply the client's positive airway pressure device:

This is the most important intervention in this scenario. Clients with severe obstructive sleep apnea rely on positive airway pressure devices, such as continuous positive airway pressure (CPAP) or bilevel positive airway pressure (BiPAP), to maintain airway patency and prevent episodes of apnea during sleep. Applying the device before leaving the client alone ensures continuous support for effective breathing.

D. Remove dentures or other oral appliance:

While removing dentures or other oral appliances may be necessary for client comfort and safety, it is not directly related to managing OSA or preventing respiratory compromise associated with opioid analgesic administration.

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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

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Correct Answer is A

Explanation

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