A nurse is caring for an older adult client who states, "I am afraid that I may fall while walking to the bathroom during the night." Which of the following actions should the nurse take?

Limit the client's fluid intake in the evening

Put the side rails up and tell the client to call the nurse before voiding

Obtain a bedside commode for the client's use

Leave a nightlight on in the client's room

Answer and Explanation

The Correct Answer is C

Choice A reason: Limiting fluid intake in the evening may reduce the need to urinate at night but does not address the client's fear of falling. It is more important to provide a safer alternative for nighttime voiding.

Choice B reason: Putting the side rails up and instructing the client to call the nurse before voiding may help, but it does not provide the most immediate and practical solution. A bedside commode offers a safer and more accessible option.

Choice C reason: Obtaining a bedside commode for the client's use directly addresses the client's concern about falling. It allows the client to void safely without having to walk to the bathroom at night, reducing the risk of falls.

Choice D reason: Leaving a nightlight on in the room can help improve visibility but does not completely eliminate the risk of falling. A bedside commode is a more effective solution.

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Correct Answer is A

Explanation

Choice A reason: Administering an antipyretic to reduce the fever and notifying the primary health care provider are the priority actions. A rapid rise in temperature in a client with multiple myeloma receiving chemotherapy could indicate a serious infection, which requires prompt medical attention.

Choice B reason: Assessing the color and content of the urine specimen for urinalysis is important but is not the immediate priority. The rapid rise in temperature is a more urgent concern.

Choice C reason: Noting the consistency of respiratory secretions and obtaining a specimen for culture is important but not the immediate priority. The primary concern is addressing the fever and notifying the healthcare provider.

Choice D reason: Comparing prior vital signs and continuing to monitor every hour is necessary but not the immediate priority. Immediate action is required to address the fever and potential infection.

A. Older adults are more likely to lose short-term memory first B. Older adults have increased reflexes C. Older adults have increased fine motor movement D. Older adults are more likely to lose long-term memory first

Correct Answer is A

Explanation

Choice A reason: Older adults commonly experience a decline in short-term memory as part of the normal aging process. This can make it more difficult to recall recent events or information.

Choice B reason: Older adults typically have decreased, not increased, reflexes due to changes in the nervous system.

Choice C reason: Older adults often experience a decline in fine motor movement, rather than an increase. Age-related changes can affect dexterity and coordination.

Choice D reason: Long-term memory is generally preserved longer in older adults compared to short-term memory. Older adults are more likely to have difficulties with recent memories.

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A nurse is caring for an older adult client who states, "I am afraid that I may fall while walking to the bathroom during the night." Which of the following actions should the nurse take?

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Naxlex Comprehensive Predictor Exams

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