A nurse is developing a plan of care for an older adult who is at risk for falls. Which of the following actions should the nurse plan to include in the plan? (Select all that apply)

Place the bedside table within the client's reach.

Teach balance and strengthening exercises.

Provide information about home safety checks.

Administer sedative at bedtime.

Lock beds and wheelchairs when not providing care.

Answer and Explanation

Correct Answer : A,B,C,E

A) Place the bedside table within the client's reach: This is an important safety measure to help prevent falls. By ensuring that the bedside table is within easy reach, the client will be less likely to try to reach for objects outside their immediate area, reducing the risk of falls from overextending or getting up unnecessarily.

B) Teach balance and strengthening exercises: Teaching balance and strengthening exercises is a key preventative measure for older adults at risk for falls. These exercises help improve muscle strength, coordination, and stability, which can significantly reduce the likelihood of falls.

C) Provide information about home safety checks: Providing information about home safety is essential to prevent falls in older adults. This includes advising the patient on eliminating hazards (like loose rugs, clutter, or inadequate lighting) and ensuring that the home environment is conducive to safety. A home safety check is part of creating a fall-prevention strategy.

D) Administer sedative at bedtime: Administering sedatives to older adults, especially those at risk for falls, can increase the likelihood of confusion, dizziness, or impaired coordination, which can lead to falls. This is not a recommended intervention. Non-pharmacologic methods for improving sleep hygiene should be prioritized over sedative medications when possible.

E) Lock beds and wheelchairs when not providing care: Locking beds and wheelchairs when not in use is a fundamental safety measure to prevent accidental movement of the bed or wheelchair. This action reduces the risk of the patient falling out of bed or from a wheelchair if they try to move or shift positions.

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Correct Answer is C

Explanation

A) History of smoking: Smoking is a modifiable risk factor, meaning it can be reduced or eliminated through lifestyle changes. While smoking significantly increases the risk of stroke, it is not a nonmodifiable risk factor. Educating clients about the benefits of quitting smoking is important to reduce stroke risk.

B) Obesity: Obesity is also a modifiable risk factor. Lifestyle changes such as diet and exercise can help manage and reduce obesity, which in turn reduces the risk of stroke. While obesity increases the likelihood of stroke, it is not considered nonmodifiable.

C) Genetics: Genetics are a nonmodifiable risk factor. A family history of stroke or certain genetic predispositions can increase the risk of stroke. These genetic factors cannot be altered, which is why they should be included in the discussion about stroke risk factors.

D) History of hypertension: Hypertension, or high blood pressure, is a significant risk factor for stroke, but it is modifiable through medication, diet, and lifestyle changes. It is not a nonmodifiable risk factor. Managing blood pressure through appropriate treatment and lifestyle changes can reduce the risk of stroke.

A. The client is a male. B. The client is 71 years old. C. The client had an appendectomy 6 months ago. D. The client has bipolar disorder.

Correct Answer is B

Explanation

A) The client is a male: While gender can influence the risk of certain health conditions, being male is not generally considered a major risk factor for acquiring a health care-associated infection (HAI). Other factors, such as age, immune status, and recent surgical procedures, are more directly linked to HAI risk.

B) The client is 71 years old: Older adults are at a higher risk for acquiring healthcare-associated infections due to age-related changes in the immune system, decreased skin integrity, and the likelihood of having multiple chronic conditions. The decreased immune response in elderly individuals makes them more susceptible to infections, including those acquired in healthcare settings.

C) The client had an appendectomy 6 months ago: While past surgeries can contribute to the risk of infections, the fact that the client had an appendectomy 6 months ago does not directly indicate a current risk for acquiring an HAI. Typically, the risk of postoperative infections decreases over time as the wound heals, especially if the surgery occurred months ago.

D) The client has bipolar disorder: Although bipolar disorder can affect a person's mental health and compliance with medical treatments, it is not a direct risk factor for acquiring a healthcare-associated infection. The focus in HAI risk assessment is generally on physical health factors such as age, immune status, surgical history, and other clinical factors rather than mental health conditions.

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A nurse is developing a plan of care for an older adult who is at risk for falls. Which of the following actions should the nurse plan to include in the plan? (Select all that apply)

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