A nurse is admitting a client to a geriatric medicine unit. Which action would the nurse implement to reduce the clients risk for falling?
Provide the client with a bedpan to reduce ambulating to the restroom
Administer pain medications sparingly in order to minimize any cognitive side effects
Place the client in a shared room with a client who is stable and oriented
Orient the client to the room and environment upon admission
The Correct Answer is D
A. Provide the client with a bedpan to reduce ambulating to the restroom: While limiting unnecessary movement can help prevent falls, using a bedpan is not the best intervention unless the patient is completely immobile.
B. Administer pain medications sparingly in order to minimize any cognitive side effects: Undertreating pain can lead to restlessness and unsteady movement, which may increase fall risk rather than prevent it.
C. Place the client in a shared room with a client who is stable and oriented: Roommate selection does not directly reduce fall risk. A shared room does not guarantee supervision or fall prevention.
D. Orient the client to the room and environment upon admission: Older adults may be disoriented in a new environment, increasing fall risk. Orienting them to the room (call light, bathroom location, bed height) helps them move safely.
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Related Questions
Correct Answer is C
Explanation
A. Avoid bathing this patient until they are stable: Hygiene is essential for preventing infection and promoting comfort. Bathing should not be entirely avoided unless the patient is critically unstable.
B. Only bathe the perineal area: While perineal care is important, other areas also require cleaning, and modifications can be made to prevent excessive exertion.
C. Perform the bath in a semi-Fowler's position: Semi-Fowler's position (30–45°) promotes lung expansion and reduces dyspnea, making it the best position for bathing a patient with breathing difficulty.
D. Delegate the task to the assistive personnel: While an assistive personnel (AP) can assist, the nurse should assess the patient first and be involved in care for clients with respiratory distress.
Correct Answer is A
Explanation
A. Educate the patient about hand hygiene with alcohol-based hand sanitizer: Standard precautions apply to all patients, including hand hygiene education. HIV is not transmitted through casual contact.
B. Notify the patient's spouse about the result and arrange for HIV testing: Patient confidentiality must be maintained. The patient should be encouraged to inform their partner, but the nurse cannot disclose the results.
C. Provide information on antibiotic therapy to help control the infection: HIV is a viral infection, not bacterial. Antibiotics do not treat HIV.
D. Initiate contact precautions with gown and gloves: HIV is bloodborne and not spread via casual contact, so contact precautions are not required unless the patient has an open wound or secondary infection.
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