The nurse is caring for a client with a history of falls. Which statement by the client indicates a need for further education on fall prevention?
"I will make sure to wear my eyeglasses all the time.
I will use the handrails when going up and down the stairs.
I will ask for help when I need to use the bathroom at night
I will keep my room well-lit during the day and night."
The Correct Answer is A
Answer: a. "I will make sure to wear my eyeglasses all the time." Explanation: The statement "I will make sure to wear my eyeglasses all the time" indicates a need for further education on fall prevention. While wearing eyeglasses can improve vision, it is not adirect fall prevention measure. It is important for the client to address other risk factors such as environmental hazards, balance, and mobility.
Incorrect choices: b. "I will use the handrails when going up and down the stairs." This statement demonstrates an understanding of using handrails for support and stability while navigating stairs, which is an appropriate fall prevention measure. c. "I will ask for help when I need to use the bathroom at night." This statement reflects the client's awareness of the need to seek assistance when necessary, reducing the risk of falls during nighttime bathroom visits. d. "I will keep my room well-lit during the day and night." This statement indicates an understanding of the importance of adequate lighting to enhance visibility and prevent falls in the client's room.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Answer: c. Implementing fall prevention interventions for the client. Explanation: After a fall, the most appropriate action for the nurse is to implement fall prevention interventions for the client. This includes reassessing the client's risk factors, modifying the environment, and providing necessary support and assistance to prevent future falls.
Incorrect choices: a. Documenting the fall incident in the client's medical record is an essential step but should follow the immediate implementation of fall prevention interventions. b. Conducting a comprehensive fall risk assessment is important, but it should be done as part of the ongoing care and assessment rather than immediately after a fall. d. Reporting the fall to the unit manager is necessary for organizational reporting purposes, but it does not directly address the client's immediate safety needs.
Correct Answer is A
Explanation
Answer: a. "I will make sure to wear my eyeglasses all the time." Explanation: The statement "I will make sure to wear my eyeglasses all the time" indicates a need for further education on fall prevention. While wearing eyeglasses can improve vision, it is not adirect fall prevention measure. It is important for the client to address other risk factors such as environmental hazards, balance, and mobility.
Incorrect choices: b. "I will use the handrails when going up and down the stairs." This statement demonstrates an understanding of using handrails for support and stability while navigating stairs, which is an appropriate fall prevention measure. c. "I will ask for help when I need to use the bathroom at night." This statement reflects the client's awareness of the need to seek assistance when necessary, reducing the risk of falls during nighttime bathroom visits. d. "I will keep my room well-lit during the day and night." This statement indicates an understanding of the importance of adequate lighting to enhance visibility and prevent falls in the client's room.
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