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 A

Explanation

A. Ask the client to read a Snellen chart: Cranial nerve II (Optic nerve) is responsible for vision. Assessing the client's ability to read a Snellen chart tests visual acuity, which is a function of cranial nerve II.

B. Listen to the client's speech: This assesses cranial nerves V (Trigeminal) and VII (Facial), which are involved in speech and facial sensation.

C. Ask the client to clench his teeth: This assesses cranial nerve V (Trigeminal), which controls jaw movement and sensation.

D. Ask the client to identify scented aromas: This assesses cranial nerve I (Olfactory), which is responsible for the sense of smell.

A. Emergency B. Time-lapse C. Focused D. Initial

Correct Answer is A

Explanation

A. Emergency: This type of assessment is rapid and focuses on identifying and treating life-threatening conditions immediately, such as profuse bleeding from a stab wound.

B. Time-lapse: This assessment compares current client data to previous data to assess progress, which is not appropriate for an acute, life-threatening situation.

C. Focused: While this is a detailed assessment of a specific problem area, an emergency assessment is needed first for immediate threats to life.

D. Initial: This is a comprehensive assessment typically conducted when a client first enters a healthcare setting, but in an emergency, the focus shifts to immediate life-saving measures.

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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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