A home health nurse is making a home visit to an older adult client. A nurse conducts a home safety assessment and screens the environment for potential hazards for falls. The nurse recommends that the client eliminate which of the following? (Select all that apply.)
Night lights
Excess clutter
Loose carpeting on the floors
Railings on the stairway
The use of a cane
Correct Answer : B,C
A. Night lights
Explanation: Night lights can enhance visibility during nighttime, reducing the risk of falls. The nurse may actually recommend using night lights strategically to illuminate pathways, especially in areas like hallways and bathrooms.
B. Excess clutter
Explanation: Excess clutter on floors can increase the risk of tripping and falling. Removing or organizing clutter helps create a safer environment for the older adult.
C. Loose carpeting on the floors
Explanation: Loose or wrinkled carpeting poses a tripping hazard. The nurse may recommend securing or replacing loose carpeting to prevent falls.
D. Railings on the stairway
Explanation: Railings on stairways are important safety features that provide support and stability. The nurse would likely recommend maintaining or installing railings to enhance stair safety.
E. The use of a cane
Explanation: If prescribed by a healthcare professional, the use of a cane can improve stability and balance for an older adult. The nurse may not recommend eliminating the use of a cane but may instead ensure that the client is using it correctly and that it is in good condition.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Balance:
The Get-Up-and-Go test assesses the patient's ability to maintain balance during the process of standing up from a chair, walking a short distance, turning around, and sitting down. Impaired balance can be a significant risk factor for falls.
B. Stride:
Stride, or the length of a person's step, is not explicitly assessed in the Get-Up-and-Go test. However, the test may indirectly provide information about the patient's walking pattern and step characteristics.
C. Flexibility:
While flexibility is not a specific focus of the Get-Up-and-Go test, the test involves movements that require a degree of joint flexibility, such as bending the knees to stand up and sit down.
D. Speed:
Speed is an important aspect of the Get-Up-and-Go test. The time taken by the patient to complete the entire sequence of standing up, walking, turning, and sitting down is considered. Slower performance on the test may indicate an increased risk of falls.
Correct Answer is A
Explanation
A. Constipation.
Explanation: Constipation is a common side effect of opioid medications like morphine. Older adults, particularly those on bed rest or with reduced mobility, are already at an increased risk of constipation. Morphine further contributes to this risk by slowing down bowel motility. Preventive measures such as promoting adequate hydration, encouraging fiber intake, and considering stool softeners can help prevent constipation in this scenario.
B. Poor solid food intake.
Explanation: While monitoring and addressing poor solid food intake are important for overall nutritional status, it may not be the immediate priority related to morphine use and postoperative care.
C. Poor liquid intake.
Explanation: Ensuring adequate fluid intake is important for overall hydration, but constipation is a more specific and immediate concern associated with opioid use.
D. Diarrhea.
Explanation: Diarrhea is not a common side effect of morphine and is less likely to be the priority for preventive care in this situation. Constipation is a more anticipated concern when opioids are prescribed.
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