A nurse is admitting a client who is at risk for falls to a medical-surgical unit. Which of the following actions should the nurse take?
Elevate full-length side rails on both sides of the client's bed.
Place the bedside table 0.9 m (3 feet) away from the bed.
Keep the client's room temperature at 18° C (64.4" F).
Provide the client with a night light.
The Correct Answer is D
A. Elevate full-length side rails on both sides of the client's bed:
While side rails are used to prevent falls, full-length side rails can pose a risk to the client. They may give a false sense of security, and there's a risk of entrapment or injury if the client tries to climb over them. The use of side rails requires careful assessment and consideration of the individual client's needs.
B. Place the bedside table 0.9 m (3 feet) away from the bed:
Placing the bedside table 0.9 m (3 feet) away from the bed may not directly address the risk of falls. The focus should be on making essential items easily accessible to the client to minimize the need for them to get out of bed, especially during the night. Placing items within the client's reach is a more practical approach.
C. Keep the client's room temperature at 18°C (64.4°F):
While maintaining a comfortable room temperature is important for the client's overall well-being, it is not a direct preventive measure for falls. Falls are more likely to be prevented by addressing environmental factors, ensuring clear pathways, and providing adequate lighting.
D. Provide the client with a night light:
This is the appropriate action. A night light helps improve visibility during nighttime, reducing the risk of falls. It allows the client to see their surroundings better and navigate the room safely if they need to get out of bed.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
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Correct Answer is A
Explanation
A. Metabolic syndrome:
Metabolic syndrome is a cluster of conditions that increase the risk of cardiovascular disease, diabetes, and stroke. These conditions include elevated blood pressure, high blood sugar, excess body fat around the waist, and abnormal cholesterol or triglyceride levels. Individuals with metabolic syndrome are at an increased risk of developing cardiovascular disease.
B. Family history of alcohol use disorder:
While a family history of alcohol use disorder may contribute to various health issues, it is not a direct risk factor for cardiovascular disease. However, excessive alcohol consumption itself can contribute to cardiovascular problems.
C. Hypotension:
Hypotension, or low blood pressure, is generally not considered a risk factor for cardiovascular disease. In fact, low blood pressure is often associated with a reduced risk of certain cardiovascular events.
D. Participation in competitive sports:
Participation in competitive sports, in general, is not a risk factor for cardiovascular disease. In fact, regular physical activity is often recommended for cardiovascular health. However, the specific type and intensity of sports activities, as w
Correct Answer is D
Explanation
A. Social worker:
While social workers play a crucial role in addressing various aspects of a patient's well-being, such as psychosocial needs and support systems, they may not be the primary healthcare team member to address the specific issue of a client with severe rheumatoid arthritis being unable to feed herself.
B. Physician assistant:
Physician assistants are medical professionals who work under the supervision of a physician. While they contribute to the overall care of the patient, they may not be the primary specialist for addressing the functional limitations and specific needs associated with severe rheumatoid arthritis.
C. Physical therapist:
Physical therapists primarily focus on physical rehabilitation, movement, and mobility. While they may be involved in the overall care plan for a patient with rheumatoid arthritis, the specific issue of hand function and activities of daily living, such as feeding, is more directly addressed by occupational therapists.
D. Occupational therapist:
The correct choice. Occupational therapists specialize in helping individuals regain or improve their ability to perform daily activities, such as feeding, dressing, and grooming. In the case of severe rheumatoid arthritis affecting the hands, an occupational therapist can work with the client to develop strategies, adaptive equipment, and exercises to enhance hand function and promote independence in activities of daily living.
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