A nurse is assisting with the care of a client.
Uses a cane to ambulate.
Macular degeneration.
Grab bar in the bathroom
Electrical cord on floor over walkway.
Throw rugs over tile floors
Correct Answer : B,D,E
Choice A reason : Using a cane to ambulate is generally a measure to improve stability and reduce the risk of falling for individuals who may have balance or mobility issues. It is not inherently a risk factor for falls; rather, it is a compensatory strategy to mitigate the risk of falls1.
Choice B reason : Macular degeneration can significantly impact visual acuity and contrast sensitivity, leading to difficulties in navigation and increasing the risk of tripping or misjudging distances. Poor vision is a well-documented risk factor for falls, especially in unfamiliar or complex environments.
Choice C reason : A grab bar in the bathroom is a safety device installed to provide stability and support for individuals while they are using the bathroom facilities. It is a preventive measure against falls and does not increase the risk of falling.
Choice D reason : An electrical cord on the floor over a walkway is a tripping hazard. It is a common home hazard that can cause falls, especially in the elderly or those with mobility and visual impairments78.
Choice E reason : Unsecured throw rugs over tile floors are a recognized fall hazard. They can easily slip underfoot or cause tripping if the edges are not secured, which is particularly dangerous in areas like the kitchen where spills can make the floor even more slippery.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason : Drinking caffeinated beverages in the evening.Caffeine is a stimulant that can significantly disrupt the sleep-wake cycle. Consuming caffeinated beverages in the evening can lead to difficulty initiating sleep because caffeine blocks the action of adenosine, a chemical that promotes sleep. The effects of caffeine can last several hours, thus affecting the quality and duration of sleep.
Choice B reason : Emotional stress activates the body's stress response, causing the release of hormones like cortisol, which increases alertness and can delay the onset of sleep. Chronic stress can lead to a hyperarousal state, making it difficult to fall asleep and stay asleep.
Choice C reason : Bright light.Exposure to bright light, especially blue light from screens, can interfere with the production of melatonin, the hormone that signals the body to prepare for sleep. This can shift the circadian rhythm and disrupt the sleep-wake cycle, making it harder to fall asleep at the usual time.
Choice D reason : A short nap during the day, typically 20-30 minutes, can be beneficial and usually does not interfere with nighttime sleep. However, longer or later naps can make it more difficult to fall asleep at night.
Correct Answer is B
Explanation
Choice A reason : Going to bed at the same time every night, even when not feeling tired, can help regulate the body's clock and aid in falling asleep at a regular time. However, lying in bed awake can lead to frustration and should be avoided. If sleep does not come within 20 minutes, it's recommended to get up and do something relaxing until feeling sleepy.
Choice B reason : Exercising can increase alertness and endorphin levels which can make it difficult to fall asleep if done too close to bedtime. Stopping exercise at least 2 hours before bedtime allows the body to wind down and prepare for sleep, making this statement correct and indicative of an understanding of good sleep hygiene practices.
Choice C reason : Watching television or engaging in other stimulating activities in the bedroom can associate the space with wakefulness rather than sleep. The light from screens can also suppress melatonin production, making it harder to fall asleep. Therefore, this statement does not reflect an understanding of the teaching on good sleep practices.
Choice D reason : Taking long naps, especially in the late afternoon or evening, can interfere with nighttime sleep. If naps are necessary, they should be limited to 20-30 minutes and taken earlier in the day. This statement suggests a misunderstanding of the impact of napping on sleep quality at night.
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