An 82-year-old client has always lived independently in the house that he and his late spouse purchased over 50 years ago. The client has few health problems, but has experienced two falls recently. Which action, by the nurse, is the priority action?

Arrange a family meeting to organize supervision for the client

Elicit what the client perceives to be the causes of and potential solutions to the falls.

Investigate what community resources may be appropriate and available.

Perform a comprehensive musculoskeletal assessment of the client.

Answer and Explanation

The Correct Answer is B

A. Arrange a family meeting to organize supervision for the client:

This option focuses on organizing supervision for the client, assuming that the client requires constant monitoring to prevent falls. While involving family members in the care plan is important, arranging a family meeting might not be the priority until the nurse understands the client's perspective on the falls and explores potential solutions.

B. Elicit what the client perceives to be the causes of and potential solutions to the falls:

This option prioritizes communication with the client to understand their perspective on the falls, including what factors they believe contributed to the falls and what solutions they envision. It respects the client's autonomy and allows them to actively participate in their care planning, which can lead to more effective fall prevention strategies.

C. Investigate what community resources may be appropriate and available:

While community resources can be valuable for supporting older adults, investigating them may not be the priority until the nurse has assessed the client's specific needs and preferences regarding fall prevention. Understanding the client's perspective and potential solutions should come first to tailor the use of community resources accordingly.

D. Perform a comprehensive musculoskeletal assessment of the client:

While assessing musculoskeletal status is important for understanding factors that could contribute to falls, conducting a comprehensive assessment may not be the immediate priority. Instead, focusing on communication with the client to understand their perspective and potential solutions should come first to inform the assessment and subsequent interventions effectively.

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Correct Answer is B

Explanation

A. Compensation for slowed response to changes in balance:

This option refers to techniques or strategies that individuals can use to compensate for changes in balance, such as adopting a wider base of support, taking smaller steps, or using handrails for support. While compensation strategies can be helpful in managing balance issues, they may not be sufficient to prevent falls, especially in individuals at increased risk due to factors like wearing an orthotic boot.

B. Use of an assistive device:

This option involves the use of devices such as canes, walkers, or crutches to provide additional support and stability during ambulation. When someone is at an increased risk for falls, especially after being prescribed an orthotic boot, using an assistive device can significantly reduce the risk of falls by providing extra support and helping to maintain balance. Teaching the client about the proper use of an assistive device is an essential aspect of fall prevention education.

C. Use of paths with support devices in case of imbalance:

This option suggests using paths or routes that have support devices, such as handrails or grab bars, available in case the individual experiences imbalance while walking. While having support devices along walking paths can be helpful, it may not always be feasible or practical. Additionally, relying solely on external support devices may not address the underlying issues contributing to the risk of falls, such as impaired balance or mobility.

D. Coordination of walking activities when family is present:

This option involves coordinating walking activities with the presence of family members. While having family members present during walking activities can provide emotional support and assistance if needed, it may not directly address the client's risk of falls or provide strategies for fall prevention. While family support is valuable, it should complement other fall prevention measures rather than serve as the primary strategy for managing fall risk.

A. "Fortunately, most people over 65 have a sufficient level of income." B. "It is reassuring older adults are receiving more concern than in decades past." C. "Most of the older clients on the unit will have come to us from nursing homes." D. "It helps that older people do not have to incur any costs for their medical care.”

Correct Answer is C

Explanation

A. "Fortunately, most people over 65 have a sufficient level of income."

This statement might not accurately reflect the reality for many older adults. While some older adults may indeed have sufficient income, there is significant variability in financial resources among older populations. Many older adults face financial challenges due to factors such as retirement savings, pensions, social security benefits, healthcare costs, and economic disparities. Therefore, this statement may not be reflective of the broader population of older adults.

B. "It is reassuring older adults are receiving more concern than in decades past."

While it is positive to recognize increased concern and attention towards the well-being of older adults, this statement does not directly address the trend of increasing admissions of older adults to subacute medical units. Moreover, without specific data or context, it is difficult to assess the accuracy of this statement in relation to current trends in healthcare utilization among older adults.

C. "Most of the older clients on the unit will have come to us from nursing homes."

This statement acknowledges a common trend observed in healthcare, where older adults are increasingly transitioning from nursing homes or long-term care facilities to subacute medical units. This reflects the evolving landscape of healthcare delivery and the need for specialized care for older adults with complex medical needs. Therefore, this statement is most reflective of current thinking about the increasing admissions of older adults to subacute medical units.

D. "It helps that older people do not have to incur any costs for their medical care.”

This statement is inaccurate. While older adults may have access to Medicare, which covers certain medical expenses, it does not cover all costs, and there may still be out-of-pocket expenses, such as copayments, deductibles, and services not covered by Medicare. Additionally, financial barriers can still exist for older adults, especially those with limited income or inadequate insurance coverage. Therefore, this statement does not accurately reflect the financial realities of older adults' healthcare costs.

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An 82-year-old client has always lived independently in the house that he and his late spouse purchased over 50 years ago. The client has few health problems, but has experienced two falls recently. Which action, by the nurse, is the priority action?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A gerontological nurse is teaching a client about safe ambulation because the client is at an increased risk for falls after being prescribed an orthotic boot. Which will the nurse teach the client?

Correct Answer is B

Explanation

Correct Answer is C

Explanation

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