The RN performs an admission assessment and determines the client is a fall risk. What is a priority nursing intervention for this client?
Provide a walker.
Place a chair on either side of the bed.
Provide a cane.
Place a fall risk wrist band on the client.
The Correct Answer is D
This is because a fall risk wristband alerts the staff and other caregivers that the client is at risk of falling and needs extra precautions and supervision. A walker, a cane, or a chair on either side of the bed are not priority interventions for a fall risk client, as they do not address the root cause of the problem or prevent potential falls.
Choice A is wrong because a walker may not be appropriate for the client’s condition or mobility level, and it may pose a tripping hazard if not used correctly.
Choice B is wrong because placing a chair on either side of the bed may limit the client’s access to the bed or the bathroom, and it may also create clutter and obstruction in the room.
Choice C is wrong because a cane may not provide enough stability or support for the client, and it may also be difficult to use in narrow spaces or on slippery surfaces.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Neglect refers to the refusal or failure to provide an elderly person with necessary care, such as food, water, shelter, personal hygiene, medicine, and other essentials of daily living. Signs and symptoms of neglect in elders can include: dehydration, malnutrition, bed sores, fractures, urinary tract infections, contractures, over-medication, elopements, and poor personal hygiene. An elderly client who is admitted to the hospital looking unkempt, with dirty clothing, and smelling of urine may be suffering from neglect by a caregiver or by themselves (self-neglect).
Choice A is wrong because institutionalism is not a type of elder abuse but a term that describes the loss of individuality and autonomy that can occur in institutional settings such as nursing homes.
Choice C is wrong because emotional abuse is the infliction of mental or emotional anguish by threat, humiliation, intimidation, or other abusive conduct. Signs and symptoms of emotional abuse in elders can include: depression, confusion, withdrawal, isolation from friends and family. An elderly client who smells of urine may not necessarily be emotionally abused.
Choice D is wrong because stubborn behavior is not a type of elder abuse but a personality trait that may or may not be present in an elderly person.
Stubborn behavior does not indicate any harm or neglect inflicted upon an older adult by others or themselves.
Correct Answer is D
Explanation
This is a method of self-care to use right after you experience a minor injury such as a sprain or strain, a minor bone injury, or a sports injury. It quickly treats pain and swelling by reducing inflammation.
Choice A is wrong because Removal (of object), Integrity checks, Condition (treat underlying), Edema relief are not related to RICE and do not form a coherent treatment regimen.
Choice B is wrong because Ibuprofen is not part of RICE and may have side effects such as stomach irritation or bleeding.
Circulatory checks are not necessary unless the compression bandage is too tight.
Choice C is wrong because Redness, Immune response, Cellular regulation, Event are not treatments but symptoms or processes of inflammation.
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