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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 ["B","C"]

Explanation

A. Night lights

Explanation: Night lights can enhance visibility during nighttime, reducing the risk of falls. The nurse may actually recommend using night lights strategically to illuminate pathways, especially in areas like hallways and bathrooms.

B. Excess clutter

Explanation: Excess clutter on floors can increase the risk of tripping and falling. Removing or organizing clutter helps create a safer environment for the older adult.

C. Loose carpeting on the floors

Explanation: Loose or wrinkled carpeting poses a tripping hazard. The nurse may recommend securing or replacing loose carpeting to prevent falls.

D. Railings on the stairway

Explanation: Railings on stairways are important safety features that provide support and stability. The nurse would likely recommend maintaining or installing railings to enhance stair safety.

E. The use of a cane

Explanation: If prescribed by a healthcare professional, the use of a cane can improve stability and balance for an older adult. The nurse may not recommend eliminating the use of a cane but may instead ensure that the client is using it correctly and that it is in good condition.

A. Assist with obtaining informed consent from the client. B. Refer to the client's advance directive for a name. C. Determine the client's inability to make reasonable decisions. D. Use the oral trail-making test to measure cognitive function.

Correct Answer is C

Explanation

A. Assist with obtaining informed consent from the client.
Explanation: Informed consent is a critical aspect of healthcare procedures, but it requires the patient to have the capacity to understand and make decisions. In this scenario, the client is intubated and on mechanical ventilation, which might compromise their ability to communicate effectively. If the client lacks capacity, obtaining consent from the durable power of attorney (POA) is more appropriate.

B. Refer to the client's advance directive for a name.
Explanation: Advance directives, including the durable POA, provide guidance on a person's wishes for healthcare decisions when they are unable to communicate. However, the advance directive may not always specify a particular person's name for decisions related to specific medical interventions. The key consideration in this situation is to determine the current decision-making capacity and involve the appropriate decision-maker if needed.

C. Determine the client's inability to make reasonable decisions.
Explanation: This is the correct answer. In this scenario, the nurse should assess the client's capacity to make decisions. If the client lacks capacity, the durable POA can be activated to make healthcare decisions on behalf of the client. Capacity involves the ability to understand relevant information, appreciate the consequences of decisions, and communicate a choice.

D. Use the oral trail-making test to measure cognitive function.
Explanation: The oral trail-making test is a cognitive screening tool, but it may not be suitable in this critical care scenario with an intubated and mechanically ventilated patient. Moreover, the primary concern in this situation is determining the capacity to make healthcare decisions, which requires a more comprehensive evaluation than a specific cognitive function test. The focus should be on decision-making capacity rather than a cognitive assessment.

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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

A home health nurse is making a home visit to an older adult client. A nurse conducts a home safety assessment and screens the environment for potential hazards for falls. The nurse recommends that the client eliminate which of the following? (Select all that apply.)

Correct Answer is ["B","C"]

Explanation

A health care provider asks the nurse about an older adult client's durable power of attorney (POA) because consent is needed for a medically necessary invasive procedure. The client has end-stage disease, is intubated, and is on mechanical ventilation. Which steps should the nurse implement?

Correct Answer is C

Explanation

The nurse wants to suggest exercise program options for an older client who is recovering losing her balance and falling. Which nursing intervention is suitable for this older adult?

An older client is being discharged from the hospital to a sub-acute unit. The client says to a nurse, "I am not sure I understand the difference between a sub-acute unit and a nursing home. Can you help me understand?" The nurse considers which of the following in formulating a response:

A nurse counseling an 85-year-old person regarding modifying driving habits would include

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A nurse conducts a comprehensive assessment of an older adult client. The nurse utilizes the Mini-Cog, a valid and reliable assessment tool to assess the individual's mental status. The nurse understands that the benefit of utilizing a standard assessment tool is what?

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The nurse is trying to improve the nutritional status of residents in the nursing home. Which recommendations should the nurse implement?