A nurse is teaching a client how to use an incentive spirometer. Which of the following statements should the nurse make?

Choice A reason: Anxiety typically causes peripheral vasoconstriction, not vasodilation, due to sympathetic nervous system activation. This “fight-or-flight” response increases catecholamine release, constricting peripheral blood vessels to redirect blood to vital organs. Vasodilation is more associated with relaxation or heat dissipation, not the heightened arousal state of anxiety, making this incorrect.

Choice B reason: Hyperventilation is a common finding in anxiety, as the sympathetic nervous system stimulates rapid, shallow breathing to increase oxygen supply during perceived stress. This can lower carbon dioxide levels, causing respiratory alkalosis, dizziness, or tingling. It reflects the body’s attempt to prepare for action, making it a hallmark physiological response in anxiety.

Choice C reason: Bradycardia, or slowed heart rate, is not typical in anxiety. Anxiety activates the sympathetic nervous system, increasing heart rate (tachycardia) to enhance blood flow to muscles and organs. Bradycardia is more associated with parasympathetic dominance, such as in relaxation or vagal stimulation, making it an incorrect finding for anxiety.

Choice D reason: Drowsiness is not expected in anxiety, which is characterized by heightened alertness and arousal due to sympathetic activation. Anxiety typically causes restlessness, difficulty concentrating, or insomnia, as the body remains in a hypervigilant state. Drowsiness may occur in other conditions, like depression, but is not a primary feature of anxiety.

Choice A reason: Applying socks without non-slip soles during ambulation increases fall risk due to reduced traction on smooth surfaces. Non-slip footwear or hospital-grade socks with grips are preferred to ensure stability. Socks alone do not provide sufficient grip, potentially leading to slips, especially in elderly or mobility-impaired clients, making this an unsafe fall prevention strategy.

Choice B reason: Locking the wheels on a client’s bed prevents unintended movement during transfers or repositioning, reducing fall risk. Stable beds ensure a secure base for clients with impaired mobility or balance, minimizing accidents. This is a standard safety measure in healthcare settings to enhance client safety during bed-related activities, such as getting in or out of bed.

Choice C reason: Placing brakes on wheelchairs ensures stability during transfers, preventing the chair from moving unexpectedly. This is critical for clients with limited mobility or strength, as an unlocked wheelchair can shift, leading to falls. Applying brakes is a fundamental safety practice in fall prevention protocols, ensuring a secure environment for safe client transfers.

Choice D reason: Keeping the bed in a high position increases fall risk, as it elevates the distance to the floor, making falls more dangerous, especially for confused or mobility-impaired clients. Beds should be kept in the lowest position when unattended to minimize injury risk, making this an incorrect strategy for fall prevention in healthcare settings.

Choice E reason: Providing under-bed lighting at night improves visibility, reducing fall risk by helping clients see obstacles or orient themselves in low-light conditions. Adequate lighting mitigates disorientation, particularly for elderly clients or those with visual impairments, supporting safe ambulation and transfers, making it an effective component of fall prevention strategies.