A client expresses anger when the nurse does not respond within 5 minutes of ringing for the nurse. Which response by the nurse is appropriate?

“I could not arrive any sooner. What can I do for you?”

“We had an emergency on the unit and that was a priority, but now I’m here.”.

“That must be frustrating for you. How can I help you right now?”

Answer and Explanation

The Correct Answer is C

Choice A rationale

Saying “I could not arrive any sooner. What can I do for you?” may come off as defensive and does not acknowledge the client’s feelings of frustration.

Choice B rationale

Saying “We had an emergency on the unit and that was a priority, but now I’m here.”. may make the client feel less important and does not acknowledge their feelings of frustration.

Choice C rationale

Saying “That must be frustrating for you. How can I help you right now?” acknowledges the client’s feelings of frustration and offers assistance, which is an appropriate response.

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Correct Answer is ["B","C","D"]

Explanation

Choice A rationale

Pupil clarity is not typically used to assess an older adult client’s risk for falls. It is more relevant in neurological assessments.

Choice B rationale

The appearance of gait is a crucial factor in assessing an older adult client’s risk for falls. Abnormalities in gait can increase the risk of falls.

Choice C rationale

Visual fields are important in assessing an older adult client’s risk for falls. Impaired visual fields can increase the risk of falls.

Choice D rationale

Visual acuity is important in assessing an older adult client’s risk for falls. Poor visual acuity can increase the risk of falls.

A. Place a pillow under the patient’s knees. B. Position a trochanter roll under each of the patient’s hips. C. Advise the patient to wear rubber-soled slippers. D. Apply an ankle-foot orthotic device to the patient’s feet.

Correct Answer is D

Explanation

Choice A rationale

Placing a pillow under the patient’s knees can actually increase the risk of plantar flexion contractures by keeping the foot in a flexed position.

Choice B rationale

Positioning a trochanter roll under each of the patient’s hips would not directly prevent plantar flexion contractures. Trochanter rolls are typically used to maintain alignment and prevent external rotation of the hip.

Choice C rationale

Advising the patient to wear rubber-soled slippers would not directly prevent plantar flexion contractures. While rubber-soled slippers can provide safety benefits such as preventing slips and falls, they do not have a direct impact on the prevention of contractures.

Choice D rationale

Applying an ankle-foot orthotic device to the patient’s feet can help maintain the foot in a neutral position, thereby reducing the risk of developing plantar flexion contractures.

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A client expresses anger when the nurse does not respond within 5 minutes of ringing for the nurse. Which response by the nurse is appropriate?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assessing an older adult client’s risk for falls.Which assessments should the nurse use to identify the client’s safety needs? (Select all that apply)

Correct Answer is ["B","C","D"]

Explanation

A nurse is caring for a patient who has herpes zoster and is inquiring about the use of complementary and alternative therapies.Which of the following actions should the nurse take to reduce the patient’s risk of developing plantar flexion contractures?

Correct Answer is D

Explanation

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