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?

Obtain a bedside commode for the client's use.

Limit the client's fluid intake in the evening.

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

Leave a nightlight on in the client's room.

Answer and Explanation

The Correct Answer is D

A. Obtain a bedside commode for the client's use: While helpful, this might not address the client's fear of walking in a dark room, and it requires transferring, which could still pose a fall risk.

B. Limit the client's fluid intake in the evening: This can prevent nocturnal trips to the bathroom but doesn't directly address safety if the client needs to get up at night.

C. Put the side rails up and tell the client to call the nurse before voiding: Side rails can sometimes increase fall risk if the client attempts to climb over them. It's more beneficial to ensure a safe environment.

D. Leave a nightlight on in the client's room: This provides adequate lighting, reducing the risk of tripping or falling in the dark, which directly addresses the client's concern about safety while walking to the bathroom.

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Correct Answer is D

Explanation

A. Testing visual acuity: This assesses cranial nerve II (Optic nerve).

B. Observing for facial symmetry: This assesses cranial nerve VII (Facial nerve).

C. Eliciting the gag reflex: This assesses cranial nerves IX and X (Glossopharyngeal and Vagus nerves).

D. Checking the pupillary response to light: This assesses cranial nerve III (Oculomotor nerve), which controls pupil constriction and eye movements.

A. Provide music as an environmental distraction. B. Make sure the room temperature is cool. C. Explain to the client what is about to happen. D. Inform the client that the provider will examine sensitive areas first

Correct Answer is C

Explanation

A. Provide music as an environmental distraction: This might help in some contexts but is not typically necessary for preparing for a physical exam. Clear communication is more important.

B. Make sure the room temperature is cool: Older adults often have reduced ability to regulate body temperature and may find cooler environments uncomfortable. A comfortable room temperature is preferable.

C. Explain to the client what is about to happen: Clear explanations can reduce anxiety, increase cooperation, and ensure that the client understands the process, which is crucial for effective assessment and trust.

D. Inform the client that the provider will examine sensitive areas first: Sensitive areas are usually examined last to maintain comfort and build trust.

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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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Correct Answer is C

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