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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","D","E"]

Explanation

A. Hearing.

While hearing impairment can affect overall awareness, it is not as directly linked to the risk of falls as vision, cognitive disorders, and blood pressure-related issues.

B. Vision.

Correct. Visual impairment can contribute to an increased risk of falls.

C. Cognitive disorders.

Correct. Cognitive impairment or disorders can impact a person's awareness and ability to navigate their environment safely.

D. Preprandial hypotension.

Correct. Low blood pressure before meals (preprandial hypotension) can contribute to dizziness and falls, especially in older adults.

E. Orthostatic hypotension.

Correct. Orthostatic hypotension, a drop in blood pressure upon standing, is a risk factor for falls.

A. Has a history of alcohol abuse B. Bathes three to four times a week C. Has a history of diabetes mellitus D. Becomes diaphoretic on warm days E. is prescribed antidepressant F. Has a history of a cerebrovascular accident CVA

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

Explanation

A. Has a history of alcohol abuse
Explanation: Alcohol can contribute to hypothermia as it causes vasodilation, leading to heat loss. It can impair the body's ability to regulate temperature.

B. Bathes three to four times a week
Explanation: While personal hygiene is important, the frequency of bathing alone may not be a direct risk factor for hypothermia. The overall environmental temperature and the individual's ability to regulate their body temperature are more critical considerations.

C. Has a history of diabetes mellitus
Explanation: Diabetes mellitus can increase the risk of hypothermia as it may affect circulation and peripheral nerve function. Impaired sensation and reduced blood flow can contribute to difficulty in maintaining body temperature.

D. Becomes diaphoretic on warm days
Explanation: Excessive sweating (diaphoresis) can contribute to the risk of hypothermia, as it leads to moisture loss from the skin, making it more challenging for the body to maintain a stable temperature.

E. Is prescribed antidepressant
Explanation: While certain medications, including some antidepressants, can affect thermoregulation, the prescription of an antidepressant alone does not necessarily indicate an increased risk of hypothermia. It is essential to consider the specific medication and its potential side effects.

F. Has a history of a cerebrovascular accident (CVA)
Explanation: Individuals with a history of a cerebrovascular accident may have impaired thermoregulation due to damage to the central nervous system. This can increase susceptibility to temperature extremes.

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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

When assessing your client who has a history of falls, you should pay particular attention to which of the following? (Select all that apply.)

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

Explanation

The nurse plans care to prevent a dangerous thermal environment for an older adult client who lives in a northern climate of the United States. Which client assessment data does the nurse recognize that can contribute to the risk of hypothermia? (Select all that apply.)

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

Explanation

A client care assistant has been assigned to feed your female client with dysphagia. Which of the following instructions would you give the assistant? (Select all that apply.)

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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?

What components are included in a person-centered community? (Select all that apply.)

An older adult client who was a veteran of World War II has just died. His widowed wife did not work and does not have sufficient funds to afford supplemental Medicare insurance. You would recommend which one of the following?

The overall temperature in the gerontological unit is 62°F during the evening shift. In documenting this concern to the administration, which factor is the most important for the health and well-being of older adults?