Which attempt by the family to prevent an older frail adult from falling causes the home health nurse concern?
Encouraging the client to use a cane wien ambulating
Keeping the side rails up on the client's bed at night
keeping several low wattage night lights crin in the evening
Installing wooden railings on the stairway to the bathroom
The Correct Answer is B
A. Encouraging the client to use a cane when ambulating.
Explanation: Encouraging the use of a cane for ambulation can provide support and stability, aiding in fall prevention.
B. Keeping the side rails up on the client's bed at night.
Explanation: Keeping side rails up on the client's bed can pose a concern as it may increase the risk of entrapment and injury. Side rails can lead to accidental entrapment, and there is a potential for the client to try to climb over them, leading to falls or injuries. The use of side rails in older adults is a safety consideration that requires careful assessment and appropriate measures to prevent harm.
C. Keeping several low wattage night lights on in the evening.
Explanation: Using low wattage night lights is a good practice to enhance visibility and prevent tripping or stumbling in low-light conditions.
D. Installing wooden railings on the stairway to the bathroom.
Explanation: Installing railings on the stairway is a proactive measure to enhance safety and stability, especially in navigating stairs, and can contribute to fall prevention.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. This response provides the family member with accurate information about the limited effectiveness of drugs in improving appetite and weight gain, along with the potential for serious side effects. It promotes informed decision-making.
B. Stating that there are no drugs that impact appetite or weight gain is not entirely accurate. Some drugs may have an impact, but the effectiveness varies, and they often come with potential side effects.
C. Blanket's statements that these drugs are not permitted in long-term care facilities are not accurate. The use of medications should be based on individual assessment and treatment plans.
D. Saying "Yes, there are some very effective drugs out there. Your mother should be on one of them" is not an appropriate response. It oversimplifies the situation and may not reflect the individualized approach needed in assessing and addressing nutritional concerns.
Correct Answer is C
Explanation
A. Decreased serum albumin levels can be an indicator of protein malnutrition, but it may not reflect overall nutritional status comprehensively. It is more specific to protein status.
B. Decreased vitamin D levels are related to a specific nutrient (vitamin D) and may indicate a deficiency in that vitamin, but it doesn't provide a broad assessment of overall nutritional status.
C. Unintentional weight loss is a key indicator of potential nutritional deficit.
Unintentional weight loss is a significant concern, especially in older adults, as it can be indicative of various underlying health issues, including malnutrition. It is a more general indicator of overall nutritional status.
D. Anorexia lasting more than 24 hours may contribute to weight loss, but it is a symptom rather than a direct measure of nutritional status. Unintentional weight loss encompasses a broader view of changes in body weight that may signal nutritional deficits.
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