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 A
Explanation
The SBAR is used to organize and standardize communication between members of the health care team about a patient’s condition. It is an acronym for Situation, Background, Assessment, and Recommendation.
Choice B is wrong because the SBAR is not used to help Physical Therapy determine the client’s abilities.
Physical Therapy may use other tools or methods to assess the client’s functional status.
Choice C is wrong because the SBAR is not used to help physicians with diagnoses.
The SBAR is a communication tool, not a diagnostic tool.
Physicians may use other sources of information or tests to make diagnoses.
Choice D is wrong because the SBAR is not used to educate clients about their disease processes.
The SBAR is a tool for interprofessional communication, not for patient education.
Clients may receive education from other sources or materials.
Correct Answer is A
Explanation
Hypothermia is a condition where the body temperature drops below 35°C (95°F) and affects the normal functioning of the body. Elderly people are more at risk for hypothermia because they have a lower muscle mass, a decreased
shiver reflex, and lower immunity. They also tend to have a lower body temperature and may not develop fevers when they contract a viral or bacterial illness.
Choice B. Normothermia is wrong because it means having a normal body temperature, which is around 37°C (98.6°F).
Choice C. Hyperthermia is wrong because it means having a high body temperature, which is above 37.5°C (99.5°F).
Hyperthermia can be caused by heat exposure, infection, inflammation, or certain medications.
Choice D. Malignant hyperthermia is wrong because it is a rare genetic disorder that causes a severe reaction to certain anesthetics or muscle relaxants.
It is not related to thermoregulation in elderly people.
Question 5.
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