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.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is D

Explanation

A. A video on breast self-examination is useful but does not ensure engagement.
B. Morbidity data for all races does not focus on African-American women specifically.
C. A listing of community members may not ensure meaningful participation.
D. Involving community leaders fosters trust and cultural relevance, increasing program effectiveness.

A. Speak to the healthcare provider about instituting physical therapy. B. Ensure placement of the nasogastric tube with an abdominal x-ray. C. Use sterile water for gastric lavage. D. Offer a pacifier for nonnutritive sucking.

Correct Answer is D

Explanation

A. Speak to the healthcare provider about instituting physical therapy: Physical therapy is not necessary in the immediate period before surgery for hypertrophic pyloric stenosis.
B. Ensure placement of the nasogastric tube with an abdominal x-ray: While confirming tube placement is important, it is not a key action for maintaining growth and development.
C. Use sterile water for gastric lavage: This is not relevant to the care of a child with hypertrophic pyloric stenosis in the pre-surgical period.
D. Offer a pacifier for nonnutritive sucking: Non-nutritive sucking provides comfort and can promote normal development in infants, even in the absence of feeding.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

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

The nurse has received funding to design a health promotion project for African-American women who are at risk for developing breast cancer. Which resource is most important in designing this program?

Correct Answer is D

Explanation

Correct Answer is D

Explanation

Exhibits New data is reviewed. Choose the most likely options for the information missing from the statements by selecting from the lists of options provided. This client is exhibiting signs of dropdown. The nurse is a mandated reporter and therefore must report the elder mistreatment todropdown.

After removing a client's dressing that is saturated with sanguineous drainage, where should the nurse place the dressing?

Exhibits Choose the most likely options for the information missing from the statement(s) by selecting from the lists of options provided. The nurse recognizes that the client has dropdownas evidenced by dropdownanddropdown.

Which assessment technique provides the most useful data when the nurse is concerned about possible urinary retention?

A client is admitted to the intensive care until (ICU) with a spinal cord injury following a motor vehicle collision. Which nurse should be contacted to coordinate the progression of the client's care?

A client with deep vein thrombosis (DVT) is receiving a continuous heparin IV infusion. The client now has tarry, black diarrhea and reports abdominal pain. Which actions should the nurse implement? Select all that apply.

The nurse is completing the admission assessment of a client with multiple sclerosis (MS). Which finding(s) should be reported to the healthcare provider immediately? Select all that apply.