While the nurse is assessing an older client's fall risk, the client reports living at home alone and never falling. Which action should the nurse take?

Record a minimal risk for falls, documenting the client's statement

Place the client on a high fall risk protocol because of advanced age.

Continue to obtain client data needed to complete the fall risk survey.

Inform the client that falls occur more often in the hospital than at home.

Answer and Explanation

The Correct Answer is C

A. Relying solely on the client’s statement is insufficient for determining fall risk. A more comprehensive assessment is needed.
B. Advanced age alone does not automatically categorize a client as high risk for falls. A complete assessment should be used to evaluate risk.
C. A thorough assessment, including a fall risk survey, is essential to accurately determine the client’s risk for falling. The fact that the client has never fallen does not automatically categorize them as low risk.
D. Informing the client that falls occur more often in the hospital than at home does not address the need for an individualized risk assessment.

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Free Nursing Study Resources

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

Explanation

A. Keeping the room brightly lit may contribute to confusion or agitation, especially in an acute stroke client.

B. Monitoring speech for changes is critical in stroke patients, as sudden changes can indicate worsening neurological status.

C. Changes in level of consciousness can indicate deterioration, and should be promptly reported to the nurse.

D. Minimizing verbal interaction may not be helpful as it could isolate the client. It's more important to provide clear and calm communication.

E. Avoiding sudden movements or sounds, such as dropping side rails or abruptly closing doors, can help reduce agitation and prevent injury.

A. Identify effective pain relief measures. B. Observe body language and movement. C. Provide a numeric pain scale. D. Ask the client to describe the pain.

Correct Answer is D

Explanation

A: Identifying effective pain relief measures is important but comes after determining the pain's characteristics. Without knowing the pain's quality, choosing the best pain relief strategy is challenging.

B: Observing body language and movement is valuable, but it does not provide specific details about the type of pain the client is experiencing.

C: A numeric pain scale measures the intensity of pain but does not assess the quality, which is important in cancer-related pain management.

D: Asking the client to describe the pain provides essential information about the quality (sharp, dull, throbbing, burning) and nature of the pain, allowing the nurse to better tailor pain management strategies.

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While the nurse is assessing an older client's fall risk, the client reports living at home alone and never falling. Which action should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client is admitted during the acute phase of a stroke. The nurse observes that the client is restless and unable to follow instructions. Which instruction(s) should the nurse provide the unlicensed assistive personnel (UAP) who is assisting with the care of the client? Select all that apply.

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

Explanation

A client with metastatic bone cancer is requesting pain medication. Which approach should the nurse use to assess the quality of the client's pain?

Correct Answer is D

Explanation

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