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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is E
Explanation
Choice A reason: Assessment is the first phase of the nursing process, where the nurse collects data about the patient's health status, needs, preferences, and goals.
Choice B reason: Analysis/Diagnosis is the second phase of the nursing process, where the nurse interprets the data and identifies the patient's problems, risks, and strengths.
Choice C reason: Planning is the third phase of the nursing process, where the nurse develops a care plan that specifies the expected outcomes, interventions, and priorities for the patient.
Choice D reason: Implementation is the fourth phase of the nursing process, where the nurse executes the care plan and performs the interventions for the patient.
Choice E reason: Evaluation is the fifth and final phase of the nursing process, where the nurse measures the effectiveness of the interventions and compares the actual outcomes with the expected outcomes. Asking the patient about their pain level after giving pain medication is an example of evaluation.
Correct Answer is C
Explanation
Choice A reason: An open wound is a concern for a diabetic client, as it can increase the risk of infection and delay the healing process. However, it does not require an immediate focused assessment, unless it is bleeding profusely, infected, or showing signs of tissue damage.
Choice B reason: Depression is a common complication of diabetes, as it can affect the client's mood, self-care, and adherence to treatment. However, it does not require an immediate focused assessment, unless the client is suicidal, psychotic, or unable to function.
Choice C reason: Chest pain is a symptom that can indicate a life-threatening condition, such as a heart attack, pulmonary embolism, or aortic dissection. It requires an immediate focused assessment, as it can compromise the client's cardiac and respiratory function and lead to death.
Choice D reason: Diabetes is a chronic condition that affects the client's blood glucose levels and can cause various complications, such as neuropathy, nephropathy, and retinopathy. However, it does not require an immediate focused assessment, unless the client is experiencing a hyperglycemic or hypoglycemic crisis.
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