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

Teach the client to shorten the stride to prevent falls.

Record the client's ability to perform ADLs safely.

Initiate a fall risk protocol for the client.

Determine the client's activity tolerance.

Answer and Explanation

The Correct Answer is B

B. Observing the client's upright posture and smooth, steady gait suggests that she is able to ambulate safely without significant risk of falls.

A. This action may be appropriate if the nurse had observed an unsteady or shuffling gait that could increase the risk of falls. However, in this scenario, the nurse has noted that the client's gait is smooth and steady, indicating good balance and stability.

C. The client's upright posture and smooth, steady gait suggest that she has good mobility and balance, which are not indicative of an increased risk of falls.

D. The client's ability to ambulate with an upright posture and smooth, steady gait indicates that she is tolerating activity well. However, the primary focus at this point should be on documenting her functional abilities and assessing her level of independence in performing ADLs safely.

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

Explanation

B. Caffeine can interfere with sleep, especially if consumed close to bedtime. Opt for decaffeinated options in the evening. Avoiding caffeinated beverages late in the day can help promote better sleep by reducing the stimulant effects of caffeine, which can interfere with falling asleep or staying asleep.

C. Establish a regular time for going to bed and getting up. Consistency helps regulate your

body’s internal clock. Try to maintain the same sleep schedule even on weekends.

A. Taking an afternoon nap to make up for missed sleep is not recommended, as napping during the day can disrupt nighttime sleep patterns and make it harder to fall asleep or stay asleep at night, especially for older adults.

D. Asking the healthcare provider for a mild sedative for bedtime may not be the first-line recommendation, as sedatives can have side effects and potential risks, especially for older adults. Non-pharmacological interventions are typically preferred for improving sleep quality.

E. Alcohol consumption before bedtime can disrupt sleep patterns and interfere with restorative sleep, particularly when combined with other substances like caffeine or sugar.

A. Positive external place. B. Motivational phrases. C. Emotional reflection. D. Tranquil sounds.

Correct Answer is A

Explanation

A. This technique involves creating vivid mental images of serene and calming environments, allowing the client to mentally escape from discomfort and focus on a peaceful setting. By immersing themselves in this imagined place, clients may experience relaxation and relief from pain.

B. Motivational phrases are statements or affirmations that inspire and encourage the client. While motivational phrases can be incorporated into guided imagery sessions to boost morale and foster positive thinking, they may not be as effective as focusing on a positive external place for managing chronic pain.

C. While emotional reflection can be an important aspect of holistic pain management, it may not be the primary focus during guided imagery sessions aimed at pain relief.

D. While soothing sounds can create a peaceful ambiance and contribute to stress reduction, they are often used as background elements rather than the primary focus of guided imagery for pain management.

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

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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

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

Explanation

The nurse is using guided imagery with a client who is experiencing chronic pain. The nurse should direct the client's attention on which focus?

Correct Answer is A

Explanation

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