The nurse assesses an older adult client’s ability to perform activities of daily living (ADLs). When observing the client ambulate, the nurse notes that the client’s posture is upright, and the gait is smooth and steady.
Which action should the nurse take next?

Initiate a fall risk protocol for the client.

Record the client’s ability to perform ADLs safely.

Determine the client’s activity tolerance.

Teach the client to shorten the stride to prevent falls.

Answer and Explanation

The Correct Answer is B

Choice A rationale

Initiating a fall risk protocol is not necessary when the client demonstrates an upright posture and a smooth, steady gait. Fall risk protocols are typically initiated when there are signs of instability or a history of falls.

Choice B rationale

Recording the client’s ability to perform ADLs safely is the appropriate action. This documentation provides a baseline for the client’s functional status and helps in planning further care. It also ensures that the client’s current abilities are noted for future reference.

Choice C rationale

Determining the client’s activity tolerance is important but not the immediate next step after observing a smooth and steady gait. This assessment can be done later to evaluate the client’s endurance and capacity for physical activities.

Choice D rationale

Teaching the client to shorten the stride to prevent falls is unnecessary when the client’s gait is already smooth and steady. This advice is more relevant for clients who show signs of instability or a tendency to fall.

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Correct Answer is C

Explanation

Choice A rationale

Giving the client a hug and saying, “It is okay to cry when you are sad,” may be comforting, but it may also be seen as intrusive and not respecting the client’s personal space. Physical touch should be used cautiously and only when the nurse is certain that it is welcome and appropriate. Additionally, this response does not encourage the client to express their feelings or provide an opportunity for the nurse to understand the underlying cause of the client’s distress.

Choice B rationale

Saying, “I am sorry to disturb you at a difficult time. This can wait until later,” acknowledges the client’s distress but does not offer immediate support or an opportunity for the client to express their feelings. It may also give the impression that the nurse is not available to provide emotional support when needed.

Choice C rationale

While touching the client’s forearm, asking, “Would you like to talk about it?” is the best response as it shows empathy and offers the client an opportunity to express their feelings. This response respects the client’s personal space while also providing a gentle touch that can be comforting. It opens the door for communication and allows the nurse to provide emotional support and address any concerns the client may have.

Choice D rationale

Saying, “This is a bad time. I can see you are upset. I can come back later,” acknowledges the client’s distress but does not offer immediate support or an opportunity for the client to express their feelings. It may also give the impression that the nurse is not available to provide emotional support when needed.

A. Apply the client’s positive airway pressure device. B. Lift and lock the side rails in place. C. Remove dentures or other oral appliances. D. Elevate the head of the bed to a 45-degree angle.

Correct Answer is A

Explanation

Choice A rationale

Clients with severe obstructive sleep apnea (OSA) are at high risk of respiratory depression when given opioid analgesics, which can further suppress breathing. The most important intervention is to apply the client’s PAP device (e.g., CPAP or BiPAP) to maintain an open airway and prevent apnea episodes.

Choice B rationale

Lifting and locking the side rails in place ensures the safety of the client but does not directly address the client’s OSA or the potential respiratory depression associated with opioid analgesic administration.

Choice C rationale

Dentures generally do not obstruct breathing unless improperly fitted. The main issue in OSA is airway collapse, which a PAP device directly addresses.

Choice D rationale

Removing dentures or other oral appliances may be necessary for client comfort and safety, but it is not directly related to managing OSA or preventing respiratory compromise associated with opioid analgesic administration.

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The nurse assesses an older adult client’s ability to perform activities of daily living (ADLs). When observing the client ambulate, the nurse notes that the client’s posture is upright, and the gait is smooth and steady. Which action should the nurse take next?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse enters a client’s room to perform a physical assessment and finds the client crying. Which response is best for the nurse to provide?

Correct Answer is C

Explanation

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Correct Answer is A

Explanation

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The nurse assesses an older adult client’s ability to perform activities of daily living (ADLs). When observing the client ambulate, the nurse notes that the client’s posture is upright, and the gait is smooth and steady.
Which action should the nurse take next?