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 ["C","D","E"]
Explanation
A. Participants in PACE programs must be able to perform their own ADLs independently.
Explanation: This statement is generally not true. PACE programs are designed to provide comprehensive and coordinated care for individuals who are frail and meet the criteria for nursing home admission. The emphasis is on maintaining participants in their homes and communities. Participants in PACE programs often have limitations in Activities of Daily Living (ADLs), and the program is designed to support them in these activities.
B. Participants in PACE programs must have been residents in a nursing home prior to enrollment in the PACE program.
Explanation: This statement is generally not true. PACE programs aim to keep individuals out of nursing homes by providing comprehensive healthcare services in a community setting. Participants in PACE programs are often those at risk of nursing home placement due to their health and functional status.
C. Participants in PACE programs must be eligible for either Medicare or Medicaid.
Explanation: This statement is generally true. PACE programs are funded through Medicare and Medicaid. Participants must be eligible for both Medicare and Medicaid to enroll in a PACE program. Medicaid eligibility may vary by state.
D. PACE programs only provide service to individuals who are age 55 and over.
Explanation: This statement is generally true. PACE programs typically serve individuals who are 55 years of age or older. However, the specific age eligibility may vary by state.
E. PACE programs provide services to individuals who meet the criteria for nursing home admission.
Explanation: This statement is generally true. PACE programs are designed for individuals who are at risk of nursing home placement due to their health and functional status. Participants must meet the criteria for nursing home admission to be eligible for PACE services.
Correct Answer is ["B","C","D","E"]
Explanation
A. Two servings of deep-colored fruit.
While fruits are recommended, the "deep-colored" specification is not a specific focus in the MyPlate for Older Adults.
B. Six or more servings of fortified, enriched, or whole grain foods.
Correct. Whole grains are an important source of fiber, vitamins, and minerals.
C. Three or more servings of low-fat or nonfat dairy products.
Correct. Dairy products provide calcium and vitamin D, important for bone health.
D. Three 8-ounce glasses of water.
Correct. Staying hydrated is crucial for overall health, especially for older adults.
E. Four or more servings of high-quality protein.
Correct. Protein is essential for muscle maintenance and repair. Sources of high-quality protein include lean meats, poultry, fish, eggs, dairy, and plant-based protein sources.
F. One or two servings of brightly colored vegetables.
While vegetables are recommended, the "brightly colored" specification is not a specific focus in the MyPlate for Older Adults.
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