An older adult woman who lives alone talks with the clinic nurse about her fears of falling at home. Which interventions should the nurse suggest? Select all that apply.

Wear an emergency response pendant at home.

Recommend installing grab bars by toilets, bathtub, and shower.

Request that a family member move in with her.

Encourage exercise to improve balance and mobility.

Have the home health nurse assess the home for fall risks.

Answer and Explanation

Correct Answer : A,B,D,E

A.   This device can be used to summon help quickly in case of a fall or other emergency.
B.   Grab bars provide extra support and can help prevent falls in areas where the risk is high.
C.   Request that a family member move in with her might be a solution for some people but it is not always practical or desirable. It's important to consider the client's preferences and independence when making recommendations.
D.   Regular exercise can help strengthen muscles and improve balance, reducing the risk of falls.
E.   A home health nurse can identify potential hazards in the home and make recommendations for modifications to improve safety.

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Correct Answer is C

Explanation

A. While napping can be beneficial for some people, a nap of 15 minutes may not address the root causes of the client’s sleep difficulties, such as stress and chronic headaches. Additionally, napping during the day can sometimes interfere with nighttime sleep.
B. Reducing or eliminating stressful situations is a valuable goal for improving overall well-being and sleep quality. However, this recommendation is often not immediately actionable or practical, as stressors in life can be difficult to eliminate completely. It’s more effective to focus on identifying and managing stress through practical and immediate interventions.
C. Assessing the client's sleep and activity patterns is a critical step in identifying potential causes of sleep disturbances. Understanding the client’s current sleep habits, daily routines, and factors affecting their sleep can help in developing an effective plan of care.
D. While medication might be necessary for some clients, it should not be the first line of intervention without a thorough assessment. PRN (as needed) medications for stress might not address the root causes of sleep issues and could potentially lead to dependence or other side effects.

A. Decrease the rate of the feeding by half. B. Observe for an allergic reaction to the formula. C. Hang a new bag of the enteral formula. D. Stop the tube feeding and assess the client.

Correct Answer is D

Explanation

A. Decreasing the rate of the feeding might be a consideration if the feeding was too rapid, but it is not the immediate priority if aspiration is suspected.
B. While it is important to monitor for allergic reactions to enteral formulas, this is not the immediate concern if aspiration is suspected. Allergic reactions would typically present with symptoms such as rash, itching, or gastrointestinal distress, and not immediately after aspiration.
C. Hanging a new bag of enteral formula is not an appropriate action if aspiration is suspected. The
priority is to ensure the client’s safety and address any complications that may arise from the aspiration, such as aspiration pneumonia.
D. Stopping the tube feeding and assessing the client is the most appropriate initial action if aspiration is suspected. Immediate assessment is necessary to determine if the client is experiencing signs of aspiration, such as coughing, wheezing, difficulty breathing, or changes in consciousness.

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An older adult woman who lives alone talks with the clinic nurse about her fears of falling at home. Which interventions should the nurse suggest? Select all that apply.

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Naxlex Comprehensive Predictor Exams

Correct Answer is C

Explanation

A client with a gastrostomy tube is receiving a continuous feeding, and the nurse suspects that the client has aspirated some of the feeding. Which action should the nurse take?

Correct Answer is D

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?

A client with a colostomy tells the nurse about making small pin holes in the drainage bag to help relieve the gas that collects. Which action should the nurse implement?

A client is ambulating with a two wheeled walker by rolling the walker forward and then moving each foot forward. The nurse notes that the client's elbows are slightly flexed when grasping the hand bar. After the client returns to the chair, which action should the nurse implement?

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Which breakfast selection indicates that the client understands the nurse's instructions about the dietary management of osteoporosis?