A nurse is caring for a client at risk for falls. Which intervention is most important for fall prevention?
Placing a sign on the client's room door indicating fall risk.
b. Encouraging the client to use the call bell for assistance.
Providing a nonskid mat on the floor beside the client's bed.
Ensuring the client has adequate lighting in the room.
The Correct Answer is B
nswer: b. Encouraging the client to use the call bell for assistance. Explanation: Encouraging the client to use the call bell for assistance is the most important intervention for fall prevention. It promotes the client's involvement in their own safety and ensures that help is readily available when needed.
Incorrect choices: a. Placing a sign on the client's room door indicating fall risk is a helpful visual reminder, but it does not actively prevent falls. c. Providing a nonskid mat on the floor beside the client's bed can reduce the risk of slipping but does not address other factors that contribute to falls. d. Ensuring the client has adequate lighting in the room is important for preventing falls, but it is not the most critical intervention. The client's ability to seek assistance when needed is more crucial.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
The correct answer is choice C. Increased insulin production.Infants with intrauterine growth restriction (IUGR) are at risk for hypoglycemia due to poor nutrient reserves and hyperinsulinism.
Hyperinsulinism is a condition where the pancreas produces too much insulin, which lowers the blood glucose level.Infants with IUGR may have hyperinsulinism because of placental insufficiency, maternal diabetes, or fetal stress.
Choice A is wrong because increased glycogen stores would protect against hypoglycemia, not cause it.
Glycogen is a form of stored glucose that can be broken down when blood glucose level is low.
Choice B is wrong because decreased gluconeogenesis would also protect against hypoglycemia, not cause it.
Gluconeogenesis is a process where the liver makes glucose from non-carbohydrate sources, such as amino acids or lactate.
Choice D is wrong because decreased glucose consumption would also protect against hypoglycemia, not cause it.
Glucose consumption is the rate at which cells use glucose for energy production.
If glucose consumption is low, blood glucose level would be high.
Correct Answer is B
Explanation
The correct answer is choice B. Hypoglycemia.
The newborn is at risk for hypoglycemia because of the maternal diabetes and the prematurity.Maternal diabetes causes fetal hyperinsulinism, which persists after birth and lowers the blood glucose level of the newborn.Prematurity causes inadequate glycogen stores and immature enzyme function, which also contribute to hypoglycemia.Hypoglycemia can cause symptoms such as tachycardia, cyanosis, seizures, and apnea.
Choice A is wrong because hyperglycemia is unlikely in a newborn with hyperinsulinism and deficient glycogen stores.
Choice C is wrong because hypertension is not a common complication of maternal diabetes or prematurity in newborns.
Choice D is wrong because hypothyroidism is not related to maternal diabetes or prematurity.Hypothyroidism can cause symptoms such as lethargy, poor feeding, jaundice, and hypotonia.
Normal ranges for blood glucose levels in newborns vary depending on the age, weight, and feeding status of the baby.
Generally, a level below 40 mg/dL (2.2 mmol/L) in symptomatic term newborns, below 45 mg/dL (2.5 mmol/L) in asymptomatic term newborns between 24 hours and 48 hours of life, or below 30 mg/dL (1.7 mmol/L) in preterm newborns in the first 48 hours is considered hypoglyc
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