A nurse is assisting with the development of a plan of care for an older adult who is at risk for falls. Which of the following actions should the nurse contribute to the plan? (Select all that apply)
Keep the bed at a comfortable working height.
Administer a sedative at bedtime.
Keep a night light on in the client's room and bathroom.
Place the bedside table within the client's reach.
Lock the wheels on beds and wheelchairs during transfers.
Correct Answer : C,D,E
Keeping a night light on in the client's room and bathroom can help reduce the risk of falls by improving visibility and orientation at night. Placing the bedside table within the client's reach can help reduce the risk of falls by making it easier for the client to access necessary items without having to get up and move around. Locking the wheels on beds and wheelchairs during transfers can help reduce the risk of falls by providing stability and preventing unwanted movement.
a. Keeping the bed at a comfortable working height is important for the nurse's comfort and safety while providing care, but it does not directly reduce the risk of falls for the client.
b. Administering a sedative at bedtime may help the client sleep, but it can also increase the risk of falls by causing drowsiness and disorientation.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
The correct answer is choice A. The client requires total nursing care.
Choice A rationale:
A Glasgow Coma Scale (GCS) score of 8 indicates a severe head injury and significant impairment in consciousness. Clients with a GCS score of 8 or less are often unable to perform basic activities of daily living independently and require total nursing care.
Choice B rationale:
A GCS score of 8 does not indicate a deep coma. Deep coma is typically associated with a GCS score of 3-4, where the client shows minimal to no response to stimuli.
Choice C rationale:
A client who is alert and oriented would have a much higher GCS score, typically between 13 and 15. A score of 8 indicates significant impairment in consciousness, not alertness and orientation.
Choice D rationale:
A GCS score of 8 does not suggest stable neurological status. Instead, it indicates severe neurological impairment, requiring close monitoring and comprehensive care.
Correct Answer is B
Explanation
If a client reports skin irritation around the upper edge of a lower-leg cast, the nurse should petal the edges of the cast. This involves applying adhesive strips or moleskin around the edges of the cast to smooth them out and prevent them from rubbing against the skin.
a. Suggesting that the client use a blunt object such as a comb to relieve the itch is not recommended as it can cause further irritation or damage to the skin.
c. Telling the client to apply lotion to the irritated skin is not recommended as it can cause further irritation or damage to the skin and may also damage the cast.
d. Bivalving the cast is not necessary for skin irritation around the upper edge of the cast. Bivalving involves cutting the cast in half to relieve pressure and is typically only done in cases of severe swelling or compartment syndrome.
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