A nurse is caring for a confused client. Which action should the nurse take to prevent this client from falling?
Reinforce how to use the call bell.
Encourage the client to use the corridor handrails.
Maintain close supervision
Place the client in a room near the nurses' station.
The Correct Answer is C
Rationale:
A. Reinforcing how to use the call bell is helpful for clients who are alert and able to follow instructions. However, a confused client may not remember or understand how to use the call bell consistently, making this intervention unreliable for fall prevention in this situation.
B. Encouraging the use of corridor handrails assumes that the client can safely ambulate independently and follow directions. A confused client may have impaired judgment, poor balance, or lack of awareness of safety precautions, which increases the risk of falling despite the presence of handrails.
C. This is the best answer because maintaining close supervision directly addresses the client’s confusion and high risk for falls. Continuous observation or frequent monitoring allows the nurse to intervene immediately if the client attempts unsafe movements, making it the most effective way to prevent falls in a confused client.
D. Placing the client in a room near the nurses’ station can help with observation, but it does not guarantee constant supervision. While it is a supportive measure, it is less effective than direct, close monitoring when a client is confused and at high risk for falls.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Rationale:
A. This finding is not concerning. Absence of pain or discomfort suggests that the client is currently stable and not experiencing overt symptoms of infection or catheter-related complications.
B. Cloudy urine with sediment can indicate a urinary tract infection (UTI) or the presence of crystalluria, which is concerning, but it is often an early sign. While it requires monitoring and possible intervention, it is less immediately alarming than a change in mental status in an elderly client.
C. These vital signs are relatively stable for an elderly adult, with only a slightly elevated pulse and blood pressure that may be within the client’s baseline range. This is not immediately concerning in the absence of other symptoms.
D. This is the most concerning finding. In elderly clients, especially those with indwelling catheters, a sudden change in mental status is often the earliest and most significant sign of infection, such as a urinary tract infection or sepsis, even before fever or vital sign changes occur. Altered mental status can present as confusion, agitation, lethargy, or disorientation and requires immediate assessment and intervention.
Correct Answer is B
Explanation
Rationale:
A. Using coercion can create fear, resentment, and decreased morale. Forcing staff to comply without addressing underlying concerns does not resolve resistance and may negatively impact team cohesion and patient care.
B. Confronting the UAP in a supportive, nonjudgmental way to encourage verbalization of feelings allows the staff member to express concerns, fears, or misunderstandings about the change. Open communication can help the nurse manager identify barriers, provide education, and foster buy-in. Addressing resistance directly and empathetically is a key strategy in change management.
C. Ignoring resistance does not address the underlying issues and may lead to ongoing noncompliance, decreased team functioning, and potential impact on patient outcomes.
D. While positive reinforcement can be helpful in encouraging participation, it is not sufficient alone when the staff member is actively resistant. Understanding the root cause of resistance first is essential before attempting rewards or incentives.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.