A nurse is caring for an older adult client who is disoriented and has a history of falls. Which of the following actions should the nurse take? (Select all that apply.)

Apply an ambulation alarm to the client's leg.

Obtain a prescription to restrain the client PRN.

Instruct the client in the use of the call light.

Raise all side rails on the client's bed.

Check on the client hourly.

Answer and Explanation

Correct Answer : A,C,E

Rationale:

A. Applying an ambulation alarm can help alert staff if the client tries to move independently, thus reducing the risk of falls.

B. Restraints should only be used as a last resort and require a physician’s order. They should not be used routinely for fall prevention.

C. Instructing the client in the use of the call light empowers them to request assistance, which can help prevent falls.

D. Raising all side rails can be considered a restraint and may increase the risk of falls or injury. It is not a recommended practice for fall prevention.

E. Checking on the client hourly ensures ongoing monitoring and timely intervention if needed, which is effective in preventing falls.

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Correct Answer is D

Explanation

Rationale:

A. HICS focuses on organizing and managing internal facility operations rather than mobilizing external multidisciplinary responders.

B. HICS does not directly ensure the availability of specific medical supplies; this is usually managed through other systems or protocols.

C. HICS is primarily concerned with internal facility management, not providing additional responders from outside agencies.

D. HICS helps to define roles, responsibilities, and reporting channels within the facility during a disaster, ensuring effective internal management.

A. Nuclear family B. Intergenerational family C. Blended family D. Extended family

Correct Answer is A

Explanation

Rationale:

A. Nuclear family refers to a family unit consisting of two parents and their children. This definition matches the description provided by the parents.

B. Intergenerational family includes multiple generations living together or having frequent contact, which is not the case here.

C. Blended family involves parents who have remarried and may include children from previous relationships, which does not apply here.

D. Extended family includes additional relatives beyond the nuclear family, such as grandparents, aunts, or uncles, which is not the case in this scenario.

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A nurse is caring for an older adult client who is disoriented and has a history of falls. Which of the following actions should the nurse take? (Select all that apply.)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is D

Explanation

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Correct Answer is A

Explanation

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