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

Answer and Explanation

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.

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Correct Answer is ["A","B","D"]

Explanation

A. The Global Deterioration Scale

Explanation: The Global Deterioration Scale (GDS) is a tool used to assess the cognitive function and stage of cognitive decline in individuals, especially those with dementia.

B. Mini Mental State Exam (MMSE)

Explanation: The Mini Mental State Exam (MMSE) is a widely used tool to assess cognitive function and screen for cognitive impairment. It evaluates various cognitive domains, including orientation, memory, attention, and language.

C. Older American's Resources and Services (OARS)

Explanation: The Older American's Resources and Services (OARS) is not a cognitive assessment tool. It is a comprehensive assessment tool that covers various domains, including physical health, mental health, and social resources.

D. Mini-Cog

Explanation: The Mini-Cog is a brief cognitive screening tool that includes a three-item recall test for memory and a clock-drawing task. It is used to quickly assess cognitive function and detect potential cognitive impairment.

E. The Barthel Index

Explanation: The Barthel Index is not a cognitive assessment tool. It is a tool used to assess an individual's ability to perform activities of daily living (ADLs), providing information about their functional independence rather than cognitive status.

A. Ensuring ready access to a toilet or commode client B. Encouraging the intake of 1 L of water each day C. Expecting a rapid and full recovery D. Toileting the client 10 to 15 minutes after meals

Correct Answer is A

Explanation

A. Ensuring ready access to a toilet or commode.

Explanation: Ensuring ready access to a toilet or commode for the client is a practical measure to address bowel incontinence. This proactive approach allows the client to respond to the urge to defecate promptly, reducing the risk of incontinence episodes.

B. Encouraging the intake of 1 L of water each day.

Explanation: While maintaining adequate hydration is important for overall bowel health, it may not directly address the issue of bowel incontinence.

C. Expecting a rapid and full recovery.

Explanation: The expectation of rapid and full recovery does not constitute a specific intervention for addressing bowel incontinence. The approach to managing bowel incontinence is typically individualized and may involve various strategies depending on the underlying causes.

D. Toileting the client 10 to 15 minutes after meals.

Explanation: Toileting the client after meals is a timing strategy that may help take advantage of the gastrocolic reflex, but it is only one aspect of a comprehensive program for managing bowel incontinence. Other interventions, such as dietary adjustments, exercise, and toileting schedules, may also be considered based on the client's specific needs.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse assesses an older adult's cognitive status using a standard assessment instrument. Which of the following are cognitive assessment tools? (Select all that apply.)

Correct Answer is ["A","B","D"]

Explanation

Which option is part of a program that addresses bowel incontinence in an older adult client?

Correct Answer is A

Explanation

Hypothermia is a medical emergency defined as a core temperature less than 95°F. Which of the following tips to prevent hypothermia should you tell your elderly client? (Select all that apply.)

A client care assistant has been assigned to feed your female client with dysphagia. Which of the following instructions would you give the assistant? (Select all that apply.)

When assessing your client who has a history of falls, you should pay particular attention to which of the following? (Select all that apply.)

The nurse wants to suggest exercise program options for an older client who is recovering losing her balance and falling. Which nursing intervention is suitable for this older adult?

The nurse plans care to prevent a dangerous thermal environment for an older adult client who lives in a northern climate of the United States. Which client assessment data does the nurse recognize that can contribute to the risk of hypothermia? (Select all that apply.)

The Bill of Rights for long-term residents was created to protect the rights of the residents in nursing homes. Which of the following examples protect these rights? (Select all that apply.)

Which patient assessment data does the nurse recognize could contribute to an older adult's risk of hyperthermia?

As a nurse caring for a cognitively impaired older adult client, you need to observe for which of the following? (Select all that apply.)