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)

A) Health promotion model: The health promotion model focuses on enhancing well-being and preventing illness through behaviors that encourage healthy lifestyles. While this model involves teaching and empowering individuals to make healthy choices, it doesn’t specifically focus on an individual’s belief about the perceived risks and benefits, as in the case of smoking cessation. Therefore, this model is not the primary one being applied in this scenario.

B) Maslow's hierarchy of needs: Maslow's hierarchy of needs is a motivational theory that suggests people are driven by a series of hierarchical needs, ranging from basic physiological needs to self-actualization. While the model addresses human needs at different levels, it doesn’t directly explain why the nurse believes the smokers will quit after learning about the benefits of smoking cessation. This model does not focus on the health behaviors related to smoking cessation in particular.

C) Health belief model: The health belief model explains health behaviors based on an individual's perceptions of the severity of a health issue, the perceived benefits of taking action, and the perceived barriers to action. In this case, the nurse is preparing a class based on the assumption that smokers will quit once they realize the benefits of not smoking, which aligns with the key concepts of the health belief model. This model emphasizes the importance of perception in motivating individuals to change unhealthy behaviors.

D) Holistic health model: The holistic health model views the individual as a whole, considering physical, emotional, social, and spiritual aspects of health. While this model might inform a broader approach to health and wellness, it does not specifically focus on the educational process of changing health behaviors, such as quitting smoking. Therefore, it is not the most appropriate model for this scenario.

A) Auscultate the entire lung region to assess lung sounds: This is the most comprehensive action. To properly assess for respiratory complications related to immobility, the nurse should auscultate all lung fields (anterior, posterior, and lateral) to detect any abnormal lung sounds such as crackles, wheezes, or decreased breath sounds. This thorough assessment helps to identify early signs of respiratory compromise, such as atelectasis or pneumonia, which are common complications of immobility.
B) Assess the patient at least every 4 hours: While regular assessment is important, the frequency of assessment should be tailored to the patient’s condition and risk factors. In critically ill or immobile patients, more frequent assessments (every 1-2 hours) may be necessary to detect changes in respiratory status early. A minimum of 4 hours may be too long between assessments for patients at risk for respiratory complications.

C) Inspect chest wall movements primarily during the expiratory cycle: The nurse should assess both the inspiratory and expiratory phases of chest wall movement, not focus solely on expiration. Inspecting both phases allows the nurse to evaluate whether the patient is having difficulty with inspiration or expiration, both of which are important indicators of respiratory function. Focusing only on expiration might miss other critical issues like shallow or labored breathing during inspiration.

D) Focus auscultation on the upper lung fields: While it is important to auscultate the upper lung fields, respiratory complications related to immobility, such as atelectasis, are more commonly observed in the lower lung fields due to gravity. Auscultating only the upper lung fields could miss abnormalities in the lower parts of the lungs, where secretions may accumulate more easily in immobile patients. Full lung auscultation is necessary for an accurate assessment.