The nurse notes that an elderly client has a history of osteoporosis. What safety measure should the nurse prioritize for this client?
Fall prevention
Pressure injury prevention
Cognitive impairment prevention
Functional decline prevention
The Correct Answer is A
Choice A reason: Fall prevention is the most important safety measure for an elderly client with osteoporosis, as falls can result in fractures and other complications. The nurse should assess the client's risk factors for falls, such as impaired vision, balance, or mobility, and implement interventions to reduce them, such as providing adequate lighting, removing clutter, and using assistive devices.
Choice B reason: Pressure injury prevention is also important for an elderly client, but not as crucial as fall prevention for a client with osteoporosis. Pressure injuries are caused by prolonged pressure on the skin, especially over bony prominences. The nurse should reposition the client frequently, use pressure-relieving devices, and monitor the skin for signs of breakdown.
Choice C reason: Cognitive impairment prevention is not a specific safety measure for an elderly client with osteoporosis, although it may affect the client's ability to follow instructions and adhere to treatment. Cognitive impairment may be caused by various factors, such as dementia, delirium, or medication side effects. The nurse should assess the client's mental status, provide orientation and stimulation, and manage any underlying causes.
Choice D reason: Functional decline prevention is not a specific safety measure for an elderly client with osteoporosis, although it may affect the client's quality of life and independence. Functional decline may be caused by various factors, such as pain, weakness, or depression. The nurse should encourage the client to participate in physical and occupational therapy, promote self-care activities, and provide emotional support.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A reason: Cataracts are a condition that causes the lens of the eye to become cloudy and opaque. They can cause symptoms such as blurred vision, glare, halos, and reduced color perception. They do not affect the shape of the lines on the Amsler grid or the center of vision.
Choice B reason: Glaucoma is a condition that causes increased pressure in the eye and damage to the optic nerve. It can cause symptoms such as gradual loss of peripheral vision, tunnel vision, and eye pain. It does not affect the shape of the lines on the Amsler grid or the center of vision.
Choice C reason: Macular degeneration is a condition that affects the macula, the central part of the retina. It can cause symptoms such as distorted vision, dark spots, and loss of central vision. It can affect the shape of the lines on the Amsler grid and the center of vision.
Choice D reason: Retinal detachment is a condition that occurs when the retina separates from the back of the eye. It can cause symptoms such as flashes, floaters, and a curtain-like vision loss. It does not affect the shape of the lines on the Amsler grid or the center of vision.
Correct Answer is A
Explanation
Choice A reason: This is the correct answer because stabilizing the object is the priority nursing action for a penetrating eye injury. Stabilizing the object prevents further damage to the eye structures and reduces the risk of infection and bleeding. The nurse should use a protective shield or cup to cover the eye and secure the object in place, and avoid applying any pressure or movement to the eye.
Choice B reason: This is not the correct answer because applying anesthetic drops is not the priority nursing action for a penetrating eye injury. Anesthetic drops may provide some relief from pain and discomfort, but they do not address the underlying problem of the object in the eye. Anesthetic drops should only be used under the direction of a physician, and after the object has been stabilized.
Choice C reason: This is not the correct answer because removing the object is not the priority nursing action for a penetrating eye injury. Removing the object is a surgical procedure that should only be performed by a qualified physician in a sterile environment. Attempting to remove the object by the nurse may cause more harm to the eye and increase the risk of complications.
Choice D reason: This is not the correct answer because applying eye ointment is not the priority nursing action for a penetrating eye injury. Eye ointment may interfere with the visualization and assessment of the eye, and may also contaminate the wound and cause infection. Eye ointment should only be used under the direction of a physician, and after the object has been stabilized.
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