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 D
Explanation
A. "I will begin 48 hr before the client's discharge." Waiting until 48 hours before discharge does not provide enough time for thorough planning, education, or addressing potential needs after discharge.
B. "I will begin once the client's insurance company approves discharge coverage." Discharge planning should not depend solely on insurance approval. It needs to be proactive and begin earlier to ensure comprehensive planning and education.
C. "I will begin once the client's discharge order is written." Starting discharge planning only after the discharge order is written does not allow adequate time for preparation and may result in rushed or incomplete planning.
D. "I will begin upon the client's admission to the facility."Discharge planning should start at admission. Early planning ensures that all aspects of post-discharge care are considered and allows ample time for education, coordination, and addressing potential barriers to successful discharge.
Correct Answer is B
Explanation
A. Pincer grasp: The pincer grasp, which involves using the thumb and forefinger to pick up small objects, typically develops around 8 to 12 months of age, not at 4 months.
B. Rolls from tummy to back: At 4 months, many infants start to develop the ability to roll from their tummy to their back. This is a typical milestone for this age and reflects developing motor skills.
C. Walks with support: Walking with support usually begins around 9 to 12 months of age, much later than 4 months.
D. Rolls from back to tummy: Rolling from back to tummy typically occurs a bit later, often around 5 to 6 months. At 4 months, rolling from tummy to back is the more expected milestone.
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