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","B","D"]
Explanation
A. Comprehensive assessment
Explanation: A comprehensive assessment involves a thorough evaluation of various cognitive functions, including memory, attention, language, problem-solving, and executive functions. This allows for a comprehensive understanding of an individual's cognitive abilities.
B. Assessing for atypical presentation of illness
Explanation: Assessing for atypical presentation of illness is relevant in a cognitive assessment because some medical conditions or illnesses can manifest with cognitive symptoms. Recognizing atypical presentations helps in identifying potential underlying causes of cognitive changes.
C. Complete blood count
Explanation: While laboratory tests like a complete blood count (CBC) may be useful in identifying certain medical conditions that could affect cognition, it is not a direct component of a cognitive assessment. Cognitive assessments typically involve clinical interviews, neuropsychological testing, and observation of cognitive functions. Blood tests and other diagnostic tools may be used to complement the cognitive assessment but are not considered components of it.
D. Differentiating delirium, dementia, and depression
Explanation: Distinguishing between delirium, dementia, and depression is crucial in a cognitive assessment. Each condition has distinct characteristics, and accurate differentiation is necessary for appropriate intervention and management.
Correct Answer is A
Explanation
A. Ensuring ready access to a toilet or commode.
Explanation: Ensuring ready access to a toilet or commode for the client is a practical measure to address bowel incontinence. This proactive approach allows the client to respond to the urge to defecate promptly, reducing the risk of incontinence episodes.
B. Encouraging the intake of 1 L of water each day.
Explanation: While maintaining adequate hydration is important for overall bowel health, it may not directly address the issue of bowel incontinence.
C. Expecting a rapid and full recovery.
Explanation: The expectation of rapid and full recovery does not constitute a specific intervention for addressing bowel incontinence. The approach to managing bowel incontinence is typically individualized and may involve various strategies depending on the underlying causes.
D. Toileting the client 10 to 15 minutes after meals.
Explanation: Toileting the client after meals is a timing strategy that may help take advantage of the gastrocolic reflex, but it is only one aspect of a comprehensive program for managing bowel incontinence. Other interventions, such as dietary adjustments, exercise, and toileting schedules, may also be considered based on the client's specific needs.
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