A nurse is admitting a client who is at risk for falls. Which of the following actions is the nurse's priority?

Explain the rounding schedule to the client

Tell the client about the visiting hours

Review meal options with the client.

Place the call light within reach of the client.

Answer and Explanation

The Correct Answer is D

A. Explain the rounding schedule to the client: While explaining the rounding schedule helps reassure the client that frequent checks will occur, it does not immediately address safety needs. Immediate actions to reduce fall risk are prioritized before providing routine information.

B. Tell the client about the visiting hours: Informing the client about visiting hours is part of general orientation but is not critical to preventing falls. Safety interventions must be implemented first to minimize risk of injury as soon as possible upon admission.

C. Review meal options with the client: Discussing meal options is part of admission and planning for nutrition, but it is not an urgent action to ensure the client's immediate safety, particularly when there is a known risk for falls.

D. Place the call light within reach of the client: Ensuring the call light is within reach allows the client to easily request assistance before attempting to move independently. This simple action is a high-priority intervention to prevent falls and promote immediate client safety.

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Correct Answer is C

Explanation

A. The infant was born large for gestational age: Being large for gestational age is not recognized as a risk factor for child maltreatment. Risk factors are more often related to family dynamics, age, and social stressors rather than birth weight alone.

B. The infant has otitis media: Otitis media, or a middle ear infection, is a common pediatric illness and is not itself a risk factor for maltreatment. It reflects normal childhood health issues rather than abuse or neglect.

C. The infant is younger than 1 year of age: Infants under 1 year are particularly vulnerable to maltreatment because of their total dependence on caregivers and inability to communicate effectively. This age group is at the highest risk for serious injury from abuse.

D. The infant's guardians are both over the age of 30: Parental age over 30 does not inherently increase the risk for child maltreatment. Other factors like substance abuse, history of being abused, and high stress levels are more closely linked to maltreatment risk.

A. "Have you thought about moving to a new neighborhood?" B. "Let's discuss how you feel when you leave your house." C. “Tell me why you have developed an aversion to leaving your house." D. "Have you tried leaving your house just once per day?"

Correct Answer is B

Explanation

A. "Have you thought about moving to a new neighborhood?": This response may dismiss the client’s feelings and doesn't directly address the anxiety. It also suggests an unrealistic solution without understanding the root cause of the client's anxiety.

B. "Let's discuss how you feel when you leave your house.": This response encourages open communication and invites the client to express their feelings. It focuses on understanding the client’s anxiety, which is the first step in addressing and managing it.

C. "Tell me why you have developed an aversion to leaving your house.": While exploring the cause of the anxiety is important, this response may come across as judgmental and could make the client feel defensive. A more open and empathetic approach would help the client feel more comfortable discussing their feelings.

D. "Have you tried leaving your house just once per day?": While this might be helpful in a later stage of treatment, it doesn't address the underlying anxiety and could be perceived as a directive instead of an empathetic, open-ended question to explore the client's emotions and experiences.

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A nurse is admitting a client who is at risk for falls. Which of the following actions is the nurse's priority?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is contributing to the development of an in-service training about child maltreatment for a group of pediatric nurses. Which of the following findings should the nurse identify as a risk factor for child maltreatment?

Correct Answer is C

Explanation

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Correct Answer is B

Explanation

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