A client begins to fall while the nurse is assisting with ambulation. What is the priority nursing intervention?
Initiate a code.
Call the charge nurse.
Guide the client safely to the floor.
Call the client's doctor.
The Correct Answer is C
The priority nursing intervention when a client begins to fall while ambulating is to guide the client safely to the floor.
This can help prevent injury and ensure the safety of the client.
CHOICE A. Initiating a code is not necessary for this situation as it is not a medical emergency.
CHOICE B AND D : Calling the charge nurse or the client’s doctor may be appropriate after the client has been safely guided to the floor and their condition has been assessed
[B] [D].
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Tell me more about it.” This statement acknowledges the difficulty of the situation and invites the patient to share their feelings and thoughts.
Choice A is incorrect because it does not acknowledge the patient’s current feelings and offers false reassurance.
Choice C is incorrect because it does not acknowledge the patient’s current feelings and may come across as intrusive.
Choice D is incorrect because it does not acknowledge the patient’s current feelings and offers false reassurance.
Correct Answer is ["A","B","C"]
Explanation
Reduced muscle strength, sensory losses like vision and hearing, and slowing of reflexes are all expected physiological changes of the older adult that can put them at risk of falls.
Reduced muscle strength can make it more difficult for older adults to maintain balance and stability.
Sensory losses like vision and hearing can affect an older adult’s ability to perceive their environment and navigate safely.
Slowing of reflexes can make it more difficult for older adults to react quickly to changes in their environment and prevent falls.
Choice D is not an answer because dementia is not a physiological change but rather a cognitive condition that can increase the risk of falls.
Choice E is not an answer because the inability to adapt is not a specific physiological change but rather a general characteristic that can increase the risk of falls.
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