The nurse is planning a fall prevention program for the residents at a long-term care facility. Which intervention is most important in providing a safe environment?

Apply a vest restraint prophylactically to confused residents.

Accompany residents older than 80 years during ambulation.

Encourage clients to wear rubber-soled shoes.

Leave the hall lights on during the night.

Answer and Explanation

The Correct Answer is C

Choice A: Applying restraints should not be the first approach in fall prevention and is associated with risks and ethical considerations.

Choice B: Accompanying residents during ambulation is a helpful practice but may not be feasible at all times. It's essential to promote independence when possible.

Choice C: Encouraging clients to wear rubber-soled shoes is an important fall prevention measure, as it can provide better traction and stability when walking.

Choice D: Leaving the hall lights on during the night may be helpful, but it is not the most critical intervention for fall prevention. Proper footwear and other measures should take precedence.

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Correct Answer is B

Explanation

Choice A: A high protein diet is generally not recommended for clients with glomerulonephritis, as it can put additional strain on the kidneys.

Choice B: In glomerulonephritis, there is impaired kidney function, and sodium and fluid restrictions are often necessary to manage fluid balance and blood pressure.

Therefore, the nurse should instruct the client to restrict sodium-rich foods and excessive oral fluids.

Choice C: A low carbohydrate diet with low glycemic index foods is not a specific dietary recommendation for managing glomerulonephritis.

Choice D: Dietary potassium restriction may vary depending on the individual client's potassium levels and needs, so it should be determined by the healthcare provider. It is not a blanket recommendation for all clients with glomerulonephritis.

A. Remove the cream from the skin immediately if pruritis occurs. B. Reapply cream in seven days to prevent re-infestation. C. Shower or bathe 8 to 14 hours after treatment to remove cream. D. Avoid areas between fingers and toes during application.

Correct Answer is C

Explanation

Choice A: Permethrin cream may cause temporary itching and skin irritation as it works to eliminate the scabies mites. Instructing the client to remove the cream immediately if pruritis occurs is not necessary; it is a common and expected side effect during treatment.

Choice B: Reapplication of permethrin is not typically done in seven days unless directed by the healthcare provider. A single application is often effective in treating scabies.

Choice C: Showering or bathing 8 to 14 hours after permethrin treatment is a common instruction to remove the cream and dead mites. This is an important part of the treatment process.

Choice D: Avoiding areas between fingers and toes during application is not necessary, as permethrin is generally safe for use on these areas. However, it should not be applied to the face or near the eyes.

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The nurse is planning a fall prevention program for the residents at a long-term care facility. Which intervention is most important in providing a safe environment?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client with glomerulonephritis is preparing for discharge and asks the nurse which kind of diet to follow upon returning home. Which dietary teaching should the nurse include in the discharge instructions?

Correct Answer is B

Explanation

An adult client receives a prescription for permethrin (Acticin Cream 5%) to treat an infestation of scabies. The nurse instructs the client to massage the cream into the skin from the head to the soles of the feet, avoiding the eyes. Which additional instruction should the nurse provide?

Correct Answer is C

Explanation

A client who has migraine headaches wants to decrease the intake of foods high in tyramine to see if that will reduce the occurrence of headaches. Which food should the nurse recommend that the client eliminate?

During the admission assessment, an older male client who has no teeth tells the nurse that he cannot find his dentures at home. His dietary prescription is a regular diet. What diet request should the nurse recommend for this client?

The nurse is performing a nutritional assessment on a client who is professional dancer. Which issue reported by the client should alert the nurse to perform further assessment?

A middle-aged client newly diagnosed with cholelithiasis is choosing the evening meal.What food choice should the nurse encourage the client to omit?

The nurse is admitting an older client with possible malnutrition. Which parameters are most indicative of the client's nutritional status?

The nurse assesses a client's fluid intake at breakfast, which consisted of oatmeal, a cup of milk, and 12 ounces of coffee. How many mL should the nurse document in the client's record? (Enter numerical value only.)

During assessment of a 2-month-old infant, the nurse notices a bluish-black discoloration over the lumbosacral area. Which action should the nurse take?