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.
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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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Sheepskin heel pad: A sheepskin heel pad provides cushioning to prevent pressure ulcers but does not prevent plantar flexion contractures as it does not keep the foot in a neutral position.
B. Abduction pillow: An abduction pillow is used to maintain hip abduction and alignment, typically after hip surgery. It does not address foot positioning or prevent plantar flexion.
C. Footboard: A footboard helps maintain the feet in dorsiflexion, preventing plantar flexion contractures. It keeps the feet at a 90-degree angle to the legs, which is essential for preventing contractures.
D. Trochanter roll: A trochanter roll is used to maintain the alignment of the hips and prevent external rotation of the legs. It does not prevent plantar flexion contractures.
Correct Answer is B
Explanation
A. Older Adult: Scoliosis screening is typically performed during adolescence, not in older adults. Older adults are more likely to be screened for other conditions such as osteoporosis.
B. Pre-adolescent/adolescent: Scoliosis screening is most commonly conducted during preadolescence and adolescence, typically around 10-15 years of age, when growth spurts occur, and the spine is most susceptible to curvature.
C. Toddler/Preschooler: Scoliosis is rarely screened in toddlers or preschoolers. This age group focuses more on developmental milestones and immunizations.
D. Infant: Scoliosis is not typically screened in infants. Screening for spinal curvature is more relevant during the rapid growth periods of adolescence.
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