A charge nurse is supervising a newly hired nurse who is instructing a client about how to use a walker. For which of the following actions should the charge nurse intervene?

The client advances the walker and takes a step towards it.

The client takes multiple steps while holding the walker.

The client grasps the walker by the hand grips on the upper bars.

The client lifts the walker as it is moved forward.

Answer and Explanation

The Correct Answer is B

Choice A reason: Advancing the walker and taking a step towards it is the correct technique, ensuring stability by moving the walker first, then stepping. This maintains balance and prevents falls, aligning with safe walker use protocols, so no intervention is needed for this action.
Choice B reason: Taking multiple steps while holding the walker compromises stability, as the walker must be repositioned after each step to ensure support. This increases fall risk, requiring the charge nurse to intervene to correct the technique and ensure the client’s safety during ambulation.
Choice C reason: Grasping the walker by the hand grips on the upper bars is correct, as it provides optimal control and balance. This standard technique supports safe mobility, and no intervention is required, as it adheres to proper walker use guidelines.
Choice D reason: Lifting the walker as it is moved forward is acceptable for lightweight or rolling walkers, depending on the client’s strength and model. While sliding is preferred for standard walkers, lifting is not inherently unsafe, so intervention is unnecessary unless improper execution is observed.

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Correct Answer is C

Explanation

Choice A reason: Experiencing delusions can contribute to agitation, but it is not the strongest predictor of violence. Delusions may lead to unpredictable behavior, but past actions are more reliable indicators, so this factor is less definitive, making it incorrect.
Choice B reason: A history of being in prison indicates past legal issues but not necessarily violent behavior. Incarceration alone is not a direct predictor of future violence, so this factor is less reliable than actual violent history, making it incorrect.
Choice C reason: A history of violent behavior is the best predictor of future violence, as past actions strongly correlate with recurrence, per evidence-based risk assessments. This reliable indicator guides safety planning, making it the correct factor to emphasize in teaching.
Choice D reason: Substance use disorder increases impulsivity and aggression risk, but it is less predictive than a documented history of violence. Substance use is a contributing factor, not the strongest indicator, so this is incorrect compared to past behavior.

A. You should contact a family member once a week to keep in touch. B. You need to move to a skilled nursing facility where they can prevent falls. C. You can have an unlicensed assistive person come to your house daily to stay with you. D. Install grab bars and remove loose rugs to reduce your risk of falling.

Correct Answer is D

Explanation

Choice A reason: Contacting a family member weekly does not directly address fall prevention for a senior living alone. While social support is valuable, it does not mitigate physical fall risks like environmental hazards. This response fails to provide practical safety measures, making it inadequate for the client’s concern.
Choice B reason: Suggesting a move to a skilled nursing facility is extreme and dismisses the client’s autonomy to remain at home. Many seniors can live safely with modifications like grab bars or assistive devices. This response does not address immediate fall prevention strategies, making it inappropriate and overly restrictive.
Choice C reason: Having an unlicensed assistive person stay daily is impractical and costly for fall prevention. It does not address environmental hazards, the primary cause of falls. Home modifications and assistive devices are more effective and sustainable, making this response less appropriate than environmental safety measures.
Choice D reason: Installing grab bars and removing loose rugs directly reduces fall risks by improving stability and eliminating tripping hazards. These evidence-based modifications are effective for seniors living alone, enhancing safety without compromising independence. This response addresses the client’s fear with practical, actionable solutions, making it correct.

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A charge nurse is supervising a newly hired nurse who is instructing a client about how to use a walker. For which of the following actions should the charge nurse intervene?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is C

Explanation

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Correct Answer is D

Explanation

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