A nurse is presenting to a class about fall prevention to a group of assisted-living residents. Which of the following statements by a resident best indicates an understanding of the teaching?

"I should get a longer cord for my telephone."

"I should use chairs without armrests."

"I should place a throw rug over electrical cords."

"It is a good idea to use the handrails in the bathroom."

Answer and Explanation

The Correct Answer is D

A. "I should get a longer cord for my telephone.": Longer cords can create tripping hazards, increasing the risk of falls. It is safer to use shorter cords or secure them properly to minimize risks. Keeping cords neatly organized and out of walkways is essential for maintaining a safe environment.

B. "I should use chairs without armrests.": Chairs with armrests can provide additional support for getting in and out of the chair, which can help prevent falls. Using chairs without armrests may make it more difficult to rise safely and could lead to losing balance during the process.

C. "I should place a throw rug over electrical cords.": Throw rugs can create tripping hazards. Placing rugs over electrical cords does not eliminate the risk and could further increase the likelihood of a fall. It's important to keep the area clear of both rugs and cords to promote safety and prevent accidents.

D. "It is a good idea to use the handrails in the bathroom.": Handrails provide stability and support when navigating potentially slippery areas, such as bathrooms, and can significantly reduce the risk of falls. Utilizing handrails allows individuals to maintain their balance and provides reassurance when moving in and out of the tub or shower.

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Correct Answer is D

Explanation

A. "After breakfast we can review the instructions for insulin self-injection again.": This statement indicates ongoing interaction and teaching with the client, suggesting that the nurse is still in the working phase of the nurse-client relationship rather than the termination phase.

B. "As soon as I get your admission papers I'll be in to talk with you about your health problem.": This statement implies the initiation of a relationship and care plan, indicating that the nurse is in the orientation phase rather than the termination phase.

C. “I see that you live near the hospital. Have you been living here a while?": This statement reflects rapport-building and exploration of the client’s background, which are part of the initial phases of the nurse-client relationship. It does not signify the termination phase.

D. “I’m going to miss talking with you every day but you are better and ready to go home now.": This statement clearly indicates the termination phase of the nurse-client relationship. It acknowledges the emotional aspect of the relationship while confirming that the client is prepared for discharge, signifying the conclusion of the care provided. This reflects a transition in the relationship as the nurse prepares to end interactions with the client.

A. Vigorously brush the client's teeth. B. Hold the toothbrush at a 90° angle. C. Place two fingers in the client's mouth. D. Turn the client to the side.

Correct Answer is D

Explanation

A. Vigorously brush the client's teeth: Vigorous brushing is not appropriate for an unconscious client. It can cause trauma to the gums or teeth and increase the risk of aspiration if the client has any residual secretions or fluids in the mouth. Gentle brushing should be employed to avoid injury.

B. Hold the toothbrush at a 90° angle: Holding the toothbrush at a 90° angle is not necessary for clients who are unconscious. A more effective angle may be around 45° to effectively clean the surfaces of the teeth while minimizing the risk of gagging or aspiration.

C. Place two fingers in the client's mouth: This action could be harmful, as placing fingers in the mouth of an unconscious client poses a risk of injury or could inadvertently trigger a gag reflex. Instead, proper oral care should be conducted using appropriate tools without placing fingers inside the mouth.

D. Turn the client to the side: Turning the client to the side is the best action as it helps prevent aspiration of secretions or fluids during oral care. This position allows for safer access to the mouth while also promoting drainage of any excess fluids, reducing the risk of choking or aspiration pneumonia.

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A nurse is presenting to a class about fall prevention to a group of assisted-living residents. Which of the following statements by a resident best indicates an understanding of the teaching?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse prepares to meet with assigned clients after receiving hand-off communication. Which statement or question demonstrates that the nurse is in the termination phase with a client?

Correct Answer is D

Explanation

A nurse is performing oral care for a client who is unconscious. Which of the following actions should the nurse take?

Correct Answer is D

Explanation

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