An older adult is brought to the clinic by the oldest adult child who found the client lying on the floor at home conscious, but unable to get up by themself. The client is unable to recall what happened. Which action should the nurse take first?

Gather a history from adult child about circumstances of previous falls.

Inform the adult child that fall prevention is a priority for older adults.

Ask the adult child to remain with the client during the examination.

Encourage the adult child to report the incident to other siblings.

Answer and Explanation

The Correct Answer is A

A.   Understanding the circumstances of previous falls can help identify any risk factors that may have contributed to the current fall. This information can be used to develop a plan to prevent future falls. By gathering information about previous falls, the nurse can develop a more comprehensive plan to address the client's specific needs and reduce the risk of future falls.
B.   While it's important to educate the adult child about fall prevention, gathering information about previous falls is a more immediate priority.
C.   Asking the adult child to remain with the client is appropriate, but it's not the most immediate action needed. Gathering information about previous falls is more important at this stage.
D.   While informing other family members may be important, it's not the most immediate action needed. Gathering information about previous falls is more important at this stage.

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Correct Answer is C

Explanation

A. Pitting edema, especially at a 4+ level, indicates significant fluid retention in the lower extremities. While this can be a concern for skin integrity and may contribute to skin breakdown due to increased pressure and reduced mobility, it is not the most direct indicator for turning schedules.
B. Hypoactive bowel sounds and infrequent bowel movements suggest gastrointestinal issues, such as constipation or reduced bowel motility. While these issues are important to address for overall client health, they do not directly impact the scheduling of turning to prevent pressure ulcers.
C. The Braden Risk Assessment Scale is a tool used to evaluate a client's risk for developing pressure ulcers. A score of 10 indicates a high risk for pressure ulcer development. This assessment directly informs the need for a more aggressive turning schedule and other preventive measures to protect skin integrity.
D. Warm, dry skin and a low-grade fever might indicate an infection or other underlying condition, but these factors are not the primary considerations for determining the turning schedule. While fever and skin temperature can be important for overall assessment and care, they do not directly impact the need for turning to prevent pressure ulcers.

A. Provide a box of tissues for the client to use when coughing. B. Assist the client in changing into a fresh hospital gown. C. Teach the client to cover the mouth with hands when coughing. D. Obtain face masks for staff to wear upon entering the room.

Correct Answer is A

Explanation

A.Providing tissues is a helpful measure for clients to use when they need to cough or sneeze. It promotes good hygiene by allowing the client to dispose of respiratory secretions properly. However, this choice does not address the immediate concern of how the client is currently coughing and the potential for spreading infection.
B.Assisting the client with a gown change may be necessary if their current gown is soiled. However, this action does not directly address the infection control issue or the client’s method of coughing. Changing the gown is secondary to addressing proper coughing techniques and infection control.
C.Teaching clients to cover their mouth with their hands is not ideal, as it can spread germs if the hands are not washed immediately afterward. Instead, clients should be taught to cough into a tissue or their elbow (not the sleeve) to minimize the spread of germs. This is a crucial component of infection control and helps reduce the risk of transmission.
D.Providing face masks for staff is an important measure in infection control, especially if the client has a respiratory illness. However, it does not address the client's current coughing technique or teach the client how to prevent the spread of infection through their own actions.

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An older adult is brought to the clinic by the oldest adult child who found the client lying on the floor at home conscious, but unable to get up by themself. The client is unable to recall what happened. Which action should the nurse take first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

In planning the turning schedule for a bedfast client, it is most important for the nurse to consider which assessment finding?

Correct Answer is C

Explanation

When entering a client's room, the nurse observes the client holding up an arm and coughing non-productively into the upper sleeve. Which action should the nurse take?

Correct Answer is A

Explanation

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