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?

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.

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

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

Answer and Explanation

The Correct Answer is A

Choice A reason: Completing the fall risk survey provides a comprehensive assessment of the client's fall risk, considering all factors.

Choice B reason: Informing the client that falls occur more often in the hospital does not complete the assessment.

Choice C reason: Recording a minimal risk based solely on the client's statement may not accurately reflect the true fall risk.

Choice D reason: Placing the client on high fall risk protocol based on age alone is not appropriate without a complete assessment.

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Correct Answer is A

Explanation

Choice A reason: Reporting the client's jaw pain to the healthcare provider is essential because jaw pain can be a symptom of osteonecrosis of the jaw, a rare but serious side effect of bisphosphonate therapy.

Choice B reason: Advising the client to gargle with warm salt water may provide temporary relief, but it does not address the underlying issue of potential osteonecrosis.

Choice C reason: Determining how the client is administering the medication is important for proper use but does not address the immediate concern of jaw pain.

Choice D reason: Confirming that this is a common symptom of osteoporosis is incorrect. Jaw pain is not a common symptom of osteoporosis and requires further evaluation.

A. Explain the need for skin exposure to sunlight without sunscreen. B. Teach the need for dietary and supplemental vitamin D. C. Instruct the client in the use of muscle strengthening exercises. D. Encourage progressive active range of motion.

Correct Answer is B

Explanation

Choice A reason: Explaining the need for skin exposure to sunlight without sunscreen is not advisable because it can increase the risk of further skin damage or skin cancer, especially in a client with a history of severe burns. Sunscreen should be used to protect the skin from harmful UV rays.

Choice B reason: Teaching the need for dietary and supplemental vitamin D is important because clients with extensive burns often have impaired vitamin D synthesis due to reduced exposure to sunlight and possible nutritional deficiencies. Vitamin D is essential for bone health and muscle function.

Choice C reason: Instructing the client in the use of muscle strengthening exercises is beneficial for overall health, but it does not directly address the specific issue of bone pain and muscle weakness related to potential vitamin D deficiency.

Choice D reason: Encouraging progressive active range of motion is important for maintaining joint flexibility and function, but it does not directly address the underlying cause of bone pain and muscle weakness in this scenario.

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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 female client is taking alendronate, a bisphosphonate, for postmenopausal osteoporosis. The client tells the nurse that she is experiencing jaw pain. How should the nurse respond?

Correct Answer is A

Explanation

One year after being discharged from the burn trauma unit, a client with a history of 40% full-thickness burns is admitted with bone pain and muscle weakness. Which intervention should the nurse include in this client's plan of care?

Correct Answer is B

Explanation

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