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. Set client-centered, measurable and realistic goals: This occurs during the planning stage, after data collection and analysis.

B. Critically analyze client data to determine priorities: This step happens after data collection during the diagnosis phase.

C. Determine effectiveness of interventions: This is part of the evaluation stage, which comes after planning and implementation.

D. Collect and organize client data: This is the first step in the nursing process, where the nurse gathers comprehensive information about the client's physical, psychological, sociocultural, developmental, and spiritual needs.

A. Bend at the knees when picking up an object. B. Relax her abdominal muscles when she lifts an object. C. Twist at the waist when she moves an object to one side. D. Hold an object away from her body as she lifts it.

Correct Answer is A

Explanation

A. Bend at the knees when picking up an object: This technique helps distribute the weight of the object and reduces strain on the back muscles.

B. Relax her abdominal muscles when she lifts an object: Tensing the abdominal muscles can provide core support, but relaxing them while lifting can increase the risk of injury.

C. Twist at the waist when she moves an object to one side: Twisting at the waist can strain the back muscles and should be avoided.

D. Hold an object away from her body as she lifts it: Holding objects close to the body reduces strain on the back muscles and is a good technique to prevent injury.

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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 A

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