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: Hyperkalemia is a common finding in the oliguric phase of acute kidney injury due to reduced excretion of potassium by the kidneys. This electrolyte imbalance can have serious cardiac effects and should be expected and monitored in these patients.

Choice B reason: An increased glomerular filtration rate (GFR) would not be expected in the oliguric phase of acute kidney injury. Typically, GFR is decreased due to reduced kidney function during this phase.

Choice C reason: Decreased creatinine levels are not expected in acute kidney injury. Creatinine levels usually increase as kidney function declines and the body cannot adequately filter waste.

Choice D reason: Hypovolemia is not typically expected in the oliguric phase of acute kidney injury, as oliguria (reduced urine output) often indicates fluid retention rather than fluid loss.

A. Chronic open-angle glaucoma B. Retinal detachment C. Cataracts D. Acute angle-closure glaucoma

Correct Answer is D

Explanation

Choice A reason: Chronic open-angle glaucoma is a gradual condition that usually progresses without noticeable symptoms until significant vision loss has occurred. It is characterized by the gradual buildup of pressure within the eye, but it does not present with sudden, severe symptoms.

Choice B reason: Retinal detachment presents with symptoms such as flashes of light, floaters, and a curtain-like shadow over the field of vision, but it does not typically cause severe pain or pressure in the eyes.

Choice C reason: Cataracts cause blurred vision and decreased visual acuity but develop slowly over time and do not cause sudden severe eye pain or extreme pressure.

Choice D reason: Acute angle-closure glaucoma is characterized by sudden, severe eye pain, blurred and decreased visual acuity, and increased intraocular pressure. This condition is a medical emergency that requires immediate treatment to prevent permanent vision loss.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Explanation

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Correct Answer is D

Explanation

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