The caregiver of an older adult client who has Alzheimer's disease and is being cared for at home reports a history of previous falls. Which of the following instructions should the nurse include in the teaching? (Select all that apply.)
Position the mattress on the floor.
Encourage physical activity prior to bedtime.
Install sensor devices on outside doors.
Remove loose rugs and clutter from walkways.
Ensure adequate lighting in hallways and bathrooms.
Correct Answer : A,C,D,E
Choice A reason: Placing the mattress on the floor reduces the risk of injury from falls out of bed, especially for clients who are prone to wandering or disorientation at night.
Choice B reason: Encouraging physical activity before bedtime may increase agitation and disrupt sleep patterns in clients with dementia. Calming routines are preferred.
Choice C reason: Sensor devices on doors help monitor wandering behavior and alert caregivers, enhancing safety and preventing elopement.
Choice D reason: Removing loose rugs and clutter minimizes tripping hazards and supports a safer environment for clients with impaired mobility and judgment.
Choice E reason: Adequate lighting reduces confusion and helps prevent falls, especially during nighttime trips to the bathroom or when navigating unfamiliar spaces.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason: This response upholds HIPAA and nursing ethical standards by refusing to confirm or deny any information about a client. It protects confidentiality fully.
Choice B reason: Suggesting contact with the hospital may indirectly confirm the person is hospitalized, breaching confidentiality.
Choice C reason: Redirecting to the high school is irrelevant and does not address the confidentiality concern appropriately.
Choice D reason: Offering any information, even vague reassurance, violates confidentiality and professional boundaries.
Correct Answer is D
Explanation
Choice A reason: Assessing social support is important but not the priority when suicide risk is suspected.
Choice B reason: Assessing for a plan is critical but should follow confirmation of current suicidal ideation.
Choice C reason: Past attempts are relevant for risk stratification but secondary to current ideation.
Choice D reason: Determining current suicidal thoughts is the first and most urgent step in suicide risk assessment to guide immediate safety interventions.
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