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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Correct Answer is C

Explanation

A. Analyze past hurts and resentments to identify the source. This strategy is more appropriate for clients in therapy to address past trauma. It is not the immediate focus for managing anxiety.
B. Concentrate on and ventilate emotions when distressed. While expressing emotions is important, it might not be the most effective strategy for generalized anxiety disorder, as it can sometimes exacerbate anxiety.
C. Focus on small achievable tasks, not taxing problems. This approach helps the client manage anxiety by breaking down large tasks into manageable steps, which reduces the overwhelming feelings associated with generalized anxiety disorder.
D. Relax and reduce the amount of effort to solve the problem. Relaxation is useful, but focusing on small, achievable tasks is a more effective way to manage anxiety in this scenario.

Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"A"}

Explanation

Describing heart rate patterns: Fetal heart rate patterns are essential indicators of the fetus's response to labor. By teaching the client about these patterns, the nurse can help the client understand what is normal and what may signal potential distress, helping to alleviate anxiety and provide education during labor.

Continuous fetal monitoring: Continuous fetal monitoring is a key tool for assessing the fetus's well-being during labor. It helps the nurse track the fetal heart rate and identify any abnormal patterns that could indicate fetal distress, such as late decelerations or significant variability.

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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 with generalized anxiety disorder does not want to communicate with friends, smokes 2 to 3 packages of cigarettes a day, and describes difficulty concentrating at work. Which coping strategy should the nurse include in the plan of care?

Correct Answer is C

Explanation

Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"A"}

Explanation

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