A nurse at an acute care facility is teaching a client about fall risk prevention strategies for use during their stay at the facility.
Which of the following statements by the client indicates an understanding of the teaching?
"I should store my personal items all together on the shelf in my bathroom.”
"I will wear a yellow wristband so everyone knows I am at risk of falling.”
"I should keep the overhead lights on at all times while I am here.”
"I will have to wear a restraint around my waist when I am sitting up in a chair.”
The Correct Answer is A
Choice A rationale:
Storing personal items together on a shelf in the bathroom promotes organization and reduces the risk of tripping or falling over scattered items. Keeping the environment tidy and free of clutter is an essential fall prevention strategy, especially in areas where the client moves frequently.
Choice B rationale:
Wearing a yellow wristband to indicate a fall risk is a common practice in healthcare facilities. However, merely wearing the wristband does not demonstrate a comprehensive understanding of fall prevention strategies. While it is essential for healthcare providers to identify patients at risk of falling, educating the patient about specific strategies to prevent falls is equally important.
Choice C rationale:
Keeping the overhead lights on at all times does not necessarily indicate an understanding of fall prevention strategies. While adequate lighting is important to prevent falls, leaving lights on continuously may not be necessary during daylight hours. It is more effective to ensure there is adequate lighting in commonly used areas and during nighttime hours.
Choice D rationale:
Wearing a restraint around the waist is not a recommended fall prevention strategy. Physical restraints are generally discouraged in healthcare settings due to ethical concerns and the potential to cause harm to the patient. Restraints can lead to complications such as pressure ulcers, loss of muscle strength, and decreased mobility.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice B rationale:
Instructing the client to gently stroke her lower abdomen is the appropriate action in this situation. Gentle stroking or tapping on the lower abdomen can stimulate the bladder reflex and promote urination. This technique can help clients who have difficulty voiding, especially when using a bedpan. It encourages relaxation of the pelvic muscles, making it easier for the client to urinate.
Choice A rationale:
Turning on the faucets in the client's sink is not a recommended action for promoting urination. While the sound of running water can sometimes trigger the need to urinate, it may not be effective for every individual. Moreover, this action may not be practical or feasible in all healthcare settings.
Choice C rationale:
Instructing the client to lean slightly backward is not an appropriate action for promoting urination. Leaning backward can put pressure on the bladder, which may make it more challenging for the client to urinate. Encouraging relaxation and using techniques like gentle abdominal stroking are more effective in this situation.
Choice D rationale:
Pouring cool water over the client's perineum is not a recommended action for promoting urination. While some individuals find warm water soothing and relaxing, pouring cold water may cause discomfort and stress, making it even more difficult for the client to urinate. Gentle stimulation and relaxation techniques are generally more effective.
Correct Answer is A
Explanation
- A. This choice is correct because a child who has autism spectrum disorder often exhibits strict adherence to routines and rituals, and may become distressed or agitated when there are changes or disruptions to their usual patterns.
- B. This choice is incorrect because difficulty paying attention to tasks is not a specific manifestation of autism spectrum disorder, but rather a common symptom of attentiondeficit/hyperactivity disorder (ADHD). A child who has autism spectrum disorder may have difficulty focusing on tasks that are not of interest to them, but may also show intense concentration on tasks that are of interest to them.
- C. This choice is incorrect because disobedience to authority figures is not a specific manifestation of autism spectrum disorder, but rather a common behavior problem in children and adolescents. A child who has autism spectrum disorder may have difficulty understanding social cues and expectations, but may also show compliance and cooperation when given clear instructions and positive reinforcement.
- D. This choice is incorrect because excessive anxiety when separated from parents is not a specific manifestation of autism spectrum disorder, but rather a common symptom of separation anxiety disorder. A child who has autism spectrum disorder may have difficulty forming attachments and expressing emotions, but may also show affection and attachment to familiar people.
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