A nurse is reinforcing home safety instructions for a patient with a history of falls.
Which statement should the nurse identify as an indication that the patient understands the instructions?

“I will place a bath seat in my shower to use when I bathe.”.

“I will keep the fluorescent ceiling light on in my room at night.”.

“I will place an area rug at the entry of my bathroom.”.

“I will keep my walker at the end of my bed.”. .

Answer and Explanation

The Correct Answer is A

Choice A rationale
Placing a bath seat in the shower is a good safety measure for a patient with a history of falls. It allows the patient to sit while bathing, reducing the risk of slipping and falling.
Choice B rationale

Keeping the fluorescent ceiling light on in the room at night can actually increase the risk of falls. It can create shadows and glare that can be disorienting, especially for older adults.
Choice C rationale
Placing an area rug at the entry of the bathroom is not recommended. Rugs can easily become tripping hazards, especially if they’re not secured to the floor.
Choice D rationale
Keeping a walker at the end of the bed can be helpful for some patients, but it’s not the best indication that the patient understands home safety instructions. It’s important that the walker is used correctly and that the patient’s home is arranged to accommodate its use.

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Correct Answer is A

Explanation

The correct answer is choice A: Provide an adaptive feeding device for the client.

Choice A rationale: Providing an adaptive feeding device, such as a built-up utensil or a swivel spoon, can help clients with limited hand movement feed themselves independently. These devices are designed to make grasping and manipulating utensils easier, promoting independence and self-care.

Choice B rationale: Placing the client in a lateral position might not directly address the issue of limited hand movement, and it could even make feeding more challenging. This position is typically used for clients with swallowing difficulties or those at risk of aspiration.

Choice C rationale: Arranging food groups clockwise on the plate may help clients with visual impairments or cognitive issues, but it would not directly assist a client with limited hand movement during feeding.

Choice D rationale: Initiating a liquid diet for the client is not the most appropriate initial action to address limited hand movement. This might be considered as a last resort if the client is unable to feed themselves with any type of adaptive device or assistance. The priority should be promoting independence and providing appropriate tools to support self-feeding.

A. Check that three fingers will fit beneath the restraints. B. Retie the restraint straps with a slipknot. C. Retie the restraint straps to the side rails. D. Remove the padding under the wrist restraints.

Correct Answer is B

Explanation

Choice A rationale

While it is important to ensure that restraints are not too tight, the issue in this scenario is not related to the tightness of the restraints.
Choice B rationale
Restraints should be tied with a slipknot to allow for quick release if necessary. A double knot may be difficult to untie quickly in an emergency.
Choice C rationale
Restraint straps should not be tied to the side rails. If the side rails are lowered, the restraints could become too loose.
Choice D rationale
The padding under the wrist restraints should not be removed. The padding helps to prevent skin damage and increase the comfort of the patient.

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A nurse is reinforcing home safety instructions for a patient with a history of falls. Which statement should the nurse identify as an indication that the patient understands the instructions?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client whose hand movement is limited. What action should the nurse take to assist the client with feeding?

Correct Answer is A

Explanation

A nurse has delegated the application of wrist restraints to an assistive personnel (AP) for a confused patient. The AP has padded the wrist restraints and secured the straps to the bed frame with a double knot. What action should the nurse take?

Correct Answer is B

Explanation

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A nurse is reinforcing home safety instructions for a patient with a history of falls. Which statement should the nurse identify as an indication that the patient understands the instructions?

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A nurse is reinforcing home safety instructions for a patient with a history of falls.
Which statement should the nurse identify as an indication that the patient understands the instructions?