A home health nurse is providing teaching to an older adult client who is at risk for falls.
Which of the following statements by the client indicates a need for further teaching?

"I will have my vision checked."

"I will put socks on when I get out of bed."

"I will put a safety bar near my toilet."

"I will put a night-light in the hallway."

Answer and Explanation

The Correct Answer is B

A.   Having vision checked is a positive step to prevent falls by addressing potential visual impairments.
B.   Wearing socks when getting out of bed increases the risk of slipping, indicating a need for further teaching.
C.   Placing a safety bar near the toilet is a preventive measure against falls.
D.   Putting a night-light in the hallway helps improve visibility and reduce the risk of tripping

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Correct Answer is A

Explanation

A. Giving oral care to a client who cannot take oral fluids is a task that can be safely delegated to an assistive personnel.
B. Checking intravenous insertion sites for signs of infiltration requires nursing judgment and assessment skills and should be performed by a licensed nurse.
C. Assessing a client's ability to ambulate involves clinical judgment and should be performed by a licensed nurse.
D. Demonstrating how to use a glucometer to a client with diabetes requires nursing knowledge and education skills and should be performed by a licensed nurse.

A. A client who has diminished vision ambulating in well-lit areas B. A client who received a diuretic 30 min ago C. A client who requires assistance with ambulation D. A client who had a tonic-clonic seizure 2 hr ago

Correct Answer is D

Explanation

A. A client with diminished vision ambulating in well-lit areas may be at risk for falling but is not at the greatest risk among the options provided.
B. A client who received a diuretic 30 min ago may experience orthostatic hypotension, which can increase the risk of falling, but it is not the highest risk.
C. A client who requires assistance with ambulation is generally at a lower risk than a client who has recently experienced a tonic-clonic seizure.
D. A client who had a tonic-clonic seizure 2 hr ago is at the greatest risk for falling due to potential residual weakness, disorientation, or postictal state following the seizure.

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A home health nurse is providing teaching to an older adult client who is at risk for falls. Which of the following statements by the client indicates a need for further teaching?

Nursing Test Bank

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A home health nurse is providing teaching to an older adult client who is at risk for falls.
Which of the following statements by the client indicates a need for further teaching?