After applying a gait belt, the nurse assists a client with ambulation. While in the hallway, the client begins to fall. Which action should the nurse implement?
Advise the client to grab hold of the gait belt for added support.
Support the client in an upright position until the belt is removed.
Use the gait belt to slowly guide the client back to the room.
Ease the client to the floor while holding the gait belt securely.
The Correct Answer is D
A. Advise the client to grab hold of the gait belt for added support: Once a client begins to fall, instructing them to hold the belt is ineffective and unsafe. Immediate action is needed to prevent injury.
B. Support the client in an upright position until the belt is removed: Attempting to maintain the client upright during a fall increases the risk of both the client and nurse sustaining injury.
C. Use the gait belt to slowly guide the client back to the room: Trying to walk a falling client back to the room is unsafe and does not prevent injury.
D. Ease the client to the floor while holding the gait belt securely: Safely lowering the client to the floor while maintaining control of the gait belt minimizes the risk of injury to both the client and the nurse, following proper fall safety procedures.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["C","D"]
Explanation
A. Excessive aerobic exercise: Moderate aerobic exercise is generally protective for cardiovascular health. The client’s symptoms occurred during normal activity, and there is no indication that his exercise is excessive or harmful, so this is less of a concern.
B. Vegetarian diet: A vegetarian diet is usually associated with lower cardiovascular risk due to reduced saturated fat intake and higher consumption of fiber and antioxidants. This is unlikely to be a contributing risk factor in this client.
C. Family health history: Both parents had heart disease, and the father had diabetes, placing the client at increased genetic risk for cardiovascular disease. Exploring family history further helps identify inherited risk factors and guides preventive strategies.
D. History of hypertension: Although the client’s current blood pressure is controlled with atenolol, hypertension is a known cardiovascular risk factor. Assessing the duration and management of prior hypertension is important to evaluate cumulative risk.
E. Sexual history: While sexual history may be relevant in some cardiovascular assessments (e.g., erectile dysfunction as a marker), it is not a primary risk factor for heart disease in this context and does not require immediate exploration.
Correct Answer is B
Explanation
A. Polydipsia and polyuria: These symptoms are more commonly associated with uncontrolled diabetes mellitus rather than hypertension. They are not direct complications of elevated blood pressure.
B. Elevated blood urea nitrogen: Hypertension can damage renal blood vessels, leading to impaired kidney function and elevated BUN levels. This is a significant complication that indicates progressive end-organ damage.
C. Dry and irritated skin: This is a nonspecific symptom that may result from dermatologic conditions, dehydration, or environmental factors. It is not typically associated with hypertension complications.
D. New onset of bradycardia: Bradycardia is not a usual complication of hypertension itself, though it may occur as a side effect of certain antihypertensive medications such as beta-blockers. It is not a primary complication to anticipate.
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