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.

Answer and Explanation

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.

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Correct Answer is ["A","C","D","E"]

Explanation

These are some of the criteria used to assist in making the diagnosis of chronic fatigue syndrome (CFS) according to the Institute of Medicine (IOM) 2015 report.

Choice B is wrong because recent exposure to influenza is not a criterion for CFS diagnosis. Although some cases of CFS may be triggered by viral infections, such as Epstein-Barr virus or human herpes virus 6, there is no specific evidence that influenza causes CFS.

Choice A is correct because CFS is not caused by a primary condition. CFS is a diagnosis of exclusion, meaning that other possible causes of fatigue, such as sleep disorders, anemia, diabetes, thyroid problems, or mental health issues, must be ruled out before making the diagnosis.

Choice C is correct because unrefreshing sleep is one of the required symptoms for CFS diagnosis. Patients with CFS may not feel better or less tired even after a full night of sleep despite the absence of specific objective sleep alterations. Choice D is correct because fatigue that is not relieved by stress reduction is another required symptom for CFS diagnosis. Patients with CFS experience post-exertional malaise (PEM), which means that their symptoms worsen after physical, mental, or emotional exertion that would not have caused a problem before the illness.

Choice E is correct because severe tiredness for 2 months or more is one of the additional manifestations that must be present for CFS diagnosis. The IOM 2015 report states that the fatigue associated with CFS must last for more than 6 months and occur at least half the time at moderate, substantial or severe intensity.

A. Instruct the client to use pursed-lip breathing. B. Plan to have the client lay down for 1 hr after meals. C. Restrict the client’s fluid intake to less than 1 L/day. D. Encourage the client to use the upper chest for respiration.

Correct Answer is A

Explanation

Pursed-lip breathing is a technique that helps to slow down the breathing rate and keep the airways open longer. This improves gas exchange and reduces the work of breathing. Pursed-lip breathing also helps to prevent air trapping and hyperinflation of the lungs, which are common complications of COPD.

Choice B is wrong because laying down for 1 hour after meals can increase the pressure on the diaphragm and make breathing more difficult. It can also increase the risk of aspiration and reflux.

Choice C is wrong because restricting the client’s fluid intake to less than 1 L/day can lead to dehydration and thickening of secretions, which can obstruct the airways and impair gas exchange. Fluid intake should be adequate to maintain hydration and thin secretions.

Choice D is wrong because using the upper chest for respiration is a sign of inefficient breathing and respiratory distress.

It can increase the oxygen demand and cause fatigue. The client should be encouraged to use the diaphragm and abdominal muscles for respiration, which are more efficient and reduce the work of breathing.

Normal ranges for oxygen saturation are 95% to 100%, for arterial blood gas pH are 7.35 to 7.45, for PaCO2 are 35 to 45 mmHg, for PaO2 are 80 to 100 mmHg, and for HCO3 are 22 to 26 mEq/L.

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The RN performs an admission assessment and determines the client is a fall risk. What is a priority nursing intervention for this client?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client with chronic fatigue syndrome. Which of the following criteria were used to assist in making this diagnosis? Select all that apply.

Correct Answer is ["A","C","D","E"]

Explanation

A nurse is contributing to the plan of care for a client who has COPD. Which of the following interventions should the nurse include in the plan of care?

Correct Answer is A

Explanation

A diabetic client presents to the acute care facility for the amputation of two gangrenous digits on her left foot. Which type of perfusion issue has caused this condition?

A nurse is utilizing the cognitive domain of learning to teach a patient about the prevention of inflammation. Which of the following is an appropriate goal for this patient?

A nurse is caring for a client who has a cloudy, opaque area over the lens of one eye. The nurse should identify that this is a manifestation of which of the following visual impairments?

A charge nurse is providing an in-service to a group of nurses on the different levels of illness prevention. The nurse should include which of the following as an example of secondary prevention?

A nurse is assessing a client who was brought to the emergency department with an ankle injury. Which of the following manifestations should the nurse identify as localized inflammation of the tissues?

A nurse is reinforcing teaching with a client who has a new diagnosis of fibromyalgia. Which of the following information should the nurse include in the teaching?

A person with anemia is prescribed erythropoietin subcutaneously. The nurse knows that erythropoietin:

A nurse is reinforcing teaching with a client about healthful sleep habits. Which of the following statements should the nurse identify as an indication that the client needs further instructions?