After assessing the older client in his bed, the nurse determines that he is at high risk for falls. The nurse leaves the room to get a fall risk sign and returns to find him on the floor pleading for help. Which of the following was the most important intervention the nurse should have implemented to prevent this event?
Provide a urinal and drinking water.
Call for someone to bring the sign.
Instruct the client to use call bell for help.
Ensure he can reach his personal items
The Correct Answer is C
A. Provide a urinal and drinking water.
Explanation: While providing a urinal and drinking water is important for the client's comfort and hydration, it may not directly address the risk of falls in this situation.
B. Call for someone to bring the sign.
Explanation: Bringing a fall risk sign is a secondary measure and not as immediate as instructing the client to use the call bell. The priority is to ensure the client's safety by addressing the need for assistance promptly.
C. Instruct the client to use the call bell for help.
Explanation: Instructing the client to use the call bell for help is a crucial intervention to ensure that the client can request assistance when needed. Promptly responding to the call bell allows healthcare providers to assist the client with activities such as getting out of bed, using the bathroom, or reaching personal items without the risk of falls. Educating and encouraging clients to use the call bell empowers them to seek assistance and promotes their safety.
D. Ensure he can reach his personal items.
Explanation: Ensuring the client can reach personal items is part of providing a comfortable environment but may not prevent falls. The critical factor in fall prevention is promoting communication and the ability to request assistance in a timely manner.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["B","C"]
Explanation
A. Night lights
Explanation: Night lights can enhance visibility during nighttime, reducing the risk of falls. The nurse may actually recommend using night lights strategically to illuminate pathways, especially in areas like hallways and bathrooms.
B. Excess clutter
Explanation: Excess clutter on floors can increase the risk of tripping and falling. Removing or organizing clutter helps create a safer environment for the older adult.
C. Loose carpeting on the floors
Explanation: Loose or wrinkled carpeting poses a tripping hazard. The nurse may recommend securing or replacing loose carpeting to prevent falls.
D. Railings on the stairway
Explanation: Railings on stairways are important safety features that provide support and stability. The nurse would likely recommend maintaining or installing railings to enhance stair safety.
E. The use of a cane
Explanation: If prescribed by a healthcare professional, the use of a cane can improve stability and balance for an older adult. The nurse may not recommend eliminating the use of a cane but may instead ensure that the client is using it correctly and that it is in good condition.
Correct Answer is B
Explanation
A. While using an assistive device can be helpful, it's more of a compensatory measure and does not directly address the improvement of balance. It's important to focus on interventions that enhance balance rather than relying solely on external devices.
B. Providing information on group exercises for balance training is a suitable intervention.
Group exercises specifically targeting balance can offer a supportive and structured environment for the older adult.
Balance training in a group setting can provide social interaction, motivation, and a sense of community, which can contribute to adherence and engagement in the program.
C. Enrolling in a general exercise program for 8 weeks may not be as targeted or tailored to the specific needs of someone recovering from balance issues. Specific balance training exercises would likely be more beneficial.
D. Learning how to exercise the core group of muscles is important for overall strength and stability, but it may not be sufficient in addressing balance issues comprehensively. Balance-specific exercises should also be included.
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