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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

Answer and Explanation

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.

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Correct Answer is A

Explanation

A. Ensuring ready access to a toilet or commode.

Explanation: Ensuring ready access to a toilet or commode for the client is a practical measure to address bowel incontinence. This proactive approach allows the client to respond to the urge to defecate promptly, reducing the risk of incontinence episodes.

B. Encouraging the intake of 1 L of water each day.

Explanation: While maintaining adequate hydration is important for overall bowel health, it may not directly address the issue of bowel incontinence.

C. Expecting a rapid and full recovery.

Explanation: The expectation of rapid and full recovery does not constitute a specific intervention for addressing bowel incontinence. The approach to managing bowel incontinence is typically individualized and may involve various strategies depending on the underlying causes.

D. Toileting the client 10 to 15 minutes after meals.

Explanation: Toileting the client after meals is a timing strategy that may help take advantage of the gastrocolic reflex, but it is only one aspect of a comprehensive program for managing bowel incontinence. Other interventions, such as dietary adjustments, exercise, and toileting schedules, may also be considered based on the client's specific needs.

A. Balance B. Stride C. Flexibility D. Speed

Correct Answer is A

Explanation

A. Balance:

The Get-Up-and-Go test assesses the patient's ability to maintain balance during the process of standing up from a chair, walking a short distance, turning around, and sitting down. Impaired balance can be a significant risk factor for falls.

B. Stride:

Stride, or the length of a person's step, is not explicitly assessed in the Get-Up-and-Go test. However, the test may indirectly provide information about the patient's walking pattern and step characteristics.

C. Flexibility:

While flexibility is not a specific focus of the Get-Up-and-Go test, the test involves movements that require a degree of joint flexibility, such as bending the knees to stand up and sit down.

D. Speed:

Speed is an important aspect of the Get-Up-and-Go test. The time taken by the patient to complete the entire sequence of standing up, walking, turning, and sitting down is considered. Slower performance on the test may indicate an increased risk of falls.

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Which attempt by the family to prevent an older frail adult from falling causes the home health nurse concern?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Which option is part of a program that addresses bowel incontinence in an older adult client?

Correct Answer is A

Explanation

The nurse assesses the quality of which of the following patient characteristics when applying the Get-Up-and-Go test from the Hendrich II Fall Risk Model?

Correct Answer is A

Explanation

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Which attempt by the family to prevent an older frail adult from falling causes the home health nurse concern?

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