As a nurse prepares an older adult client for bed on the first night of her hospital stay, the client says, "I am afraid that I may fall getting to the bathroom during the night. I tend to get a bit disoriented in new surroundings." Which of the following actions should the nurse take?

Offer to request a prescription for an indwelling urinary catheter.

Keep a night light on in the client's room.

Put the side rails up and tell the client to call for assistance to the bathroom.

Limit the client's fluid intake in the evening.

Answer and Explanation

The Correct Answer is B

A. Offer to request a prescription for an indwelling urinary catheter.

Indwelling urinary catheters come with their own set of risks and complications. It is generally not recommended to use them solely for the purpose of preventing falls unless there are other medical indications for their use. Catheters increase the risk of infection and other complications, and their use should be based on clear medical necessity.

B. Keep a night light on in the client's room.

This option directly addresses the client's concern about falling during the night. Providing a night light in the room helps to alleviate disorientation, making it safer for the client to navigate to the bathroom. It is a practical and non-invasive intervention.

C. Put the side rails up and tell the client to call for assistance to the bathroom.

While using side rails can be a fall prevention measure, it's important to consider that they are not without risks. Side rails can lead to entrapment or injury if not used appropriately. In addition, telling the client to call for assistance is good advice, but relying solely on this instruction may not address the immediate concern of disorientation in new surroundings.

D. Limit the client's fluid intake in the evening.

While limiting fluid intake in the evening might reduce the frequency of bathroom trips, it is not the most appropriate response to the client's concern. Dehydration can lead to other health issues and should not be used as the primary strategy for fall prevention.

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

Explanation

A. Client understands the surgical procedure:

The client should have a clear understanding of the proposed surgical procedure, its risks, benefits, alternatives, and potential complications.

B. Voluntary consent is given:

The client's consent should be given voluntarily, without coercion or pressure from healthcare providers or others.

C. Client's ability to read the consent form:

While it is helpful for clients to be able to read the consent form, the ability to read the form is not a requirement for valid consent. The information should be explained verbally if the client cannot read.

D. Client's ability to pay for the consented surgical procedure:

The client's ability to pay for the procedure is not a factor in obtaining informed consent. Financial considerations do not affect the validity of the consent.

E. Disclosure of the treatment is provided:

Healthcare providers must disclose information about the proposed treatment, including its nature, purpose, risks, benefits, and potential alternatives, allowing the client to make an informed decision.

A. "Unlike an x-ray, the MRI allows you to move around a bit." B. "Your exposure to radiation will be minimal." C. "You will not be able to talk to the technician during the procedure." D. "You'll have to remove metal objects such as watches and body jewelry."

Correct Answer is D

Explanation

A. "Unlike an x-ray, the MRI allows you to move around a bit":

This statement is not accurate. During an MRI, it is important for the client to remain as still as possible to obtain clear images. Movement can result in blurred images.

B. "Your exposure to radiation will be minimal":

This statement is not applicable to MRI, as MRI does not use ionizing radiation. It uses a strong magnetic field and radio waves to generate images, making it different from x-rays in terms of radiation exposure.

C. "You will not be able to talk to the technician during the procedure":

While it is essential for the client to remain still during an MRI, communication with the technician is generally possible through an intercom system. The client may be given instructions and reassurance during the procedure.

D. "You'll have to remove metal objects such as watches and body jewelry":

This is the correct statement. Metal objects can interfere with the magnetic field used in MRI and can pose a safety risk. Therefore, clients are required to remove any metal objects before undergoing an MRI.

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As a nurse prepares an older adult client for bed on the first night of her hospital stay, the client says, "I am afraid that I may fall getting to the bathroom during the night. I tend to get a bit disoriented in new surroundings." Which of the following actions should the nurse take?

Nursing Test Bank

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

Explanation

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Correct Answer is D

Explanation

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