When caring for the elderly the nurse must implement which measure for client safety?
Keep the environment free of obstacles
Raise the bed for client ease upon exiting
Avoid bright lighting
Keep linens away from nursing uniform
The Correct Answer is A
A. This is essential to prevent falls, which are a common and serious risk for the elderly. A clutter-free environment allows for safe and easy mobility.
B. Raising the bed, can actually increase the risk of falls if the bed is too high for safe exit.
C. Bright lighting can cause glare and visual discomfort for elderly individuals, especially those with age- related eye conditions such as cataracts or macular degeneration. However, adequate lighting is crucial for safety. The key is to provide sufficient lighting that is evenly distributed and free of glare or harsh shadows, which can help prevent falls.
D. While keeping linens away from the nursing uniform is good practice for infection control, it does not directly relate to the immediate physical safety of the client in the same way that a clear environment does.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
D. Rectal temperature measurement involves inserting a thermometer into the rectum. This method provides the most accurate reflection of core body temperature because the rectum closely mirrors internal body temperature. It is often used in infants, young children, and patients who are unable to have their temperature taken orally.
A. Axillary temperature measurement involves placing the thermometer in the armpit. This method is convenient and non-invasive but tends to provide the lowest temperature readings compared to other sites. It is suitable for screening purposes but may not be as accurate as other methods.
B. Skin temperature can vary widely based on environmental factors, circulation, and local skin conditions. Surface skin temperature may not accurately reflect core body temperature and is not typically used for precise temperature measurement in clinical settings.
C. Oral temperature measurement involves placing the thermometer under the tongue. This method is commonly used and provides a reasonably accurate reflection of core body temperature. It is convenient and generally well-tolerated by clients who are conscious and able to cooperate.
Correct Answer is A
Explanation
A. The pulmonic valve is best auscultated at the second intercostal space (ICS) on the left sternal border. This is where the area corresponding to the pulmonic valve is most accurately heard due to the anatomical positioning of the heart.
B. This area does not correspond to any valvular area.
C. This location corresponds to the aortic valve, not the pulmonic valve. The aortic valve is best auscultated at the second ICS, right sternal border.
D. This location corresponds to the tricuspid valve, not the pulmonic valve. The tricuspid valve is best auscultated at the fourth or fifth ICS along the left sternal border.
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