The nurse is caring for a group of clients who all need bed alarms to prevent falls. Which client should the nurse ensure has the bed alarm enabled first?
A client with an abnormal gait who takes an anticonvulsant medication.
A client with lower extremity weakness and dementia.
A client with visual impairment who calls for assistance when needed.
A client with hypotension who uses a walker to ambulate.
The Correct Answer is B
A. A client with an abnormal gait who takes an anticonvulsant medication: This client is at increased fall risk due to gait instability and potential medication side effects. However, if the client can request assistance and is cognitively intact, the immediate risk is lower than for clients with impaired judgment.
B. A client with lower extremity weakness and dementia: Dementia impairs judgment, awareness of limitations, and the ability to request help, while lower extremity weakness compromises mobility. This combination places the client at highest immediate risk for unassisted falls, making activation of the bed alarm a priority.
C. A client with visual impairment who calls for assistance when needed: While visual deficits increase fall risk, the client’s ability to recognize limitations and seek help mitigates immediate danger. The fall risk is present but less urgent than for a cognitively impaired client who may attempt to get out of bed unassisted.
D. A client with hypotension who uses a walker to ambulate: Hypotension may cause dizziness, increasing fall risk during ambulation. However, if the client waits for assistance and uses mobility aids appropriately, the risk of unassisted falls is lower than in a client with dementia and mobility weakness.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Presence of slough: Slough is yellow, white, or stringy tissue in the wound bed that represents dead or devitalized tissue. Its presence indicates impaired healing and requires debridement for the wound to progress.
B. Presence of granulation tissue: Granulation tissue is pink or red, moist, and composed of new connective tissue and capillaries. Its presence signals healthy wound healing, as it fills the wound bed and provides a foundation for epithelialization.
C. Presence of necrotic tissue: Necrotic tissue is black, brown, or gray and consists of dead cells. It impedes healing, increases infection risk, and must be removed to allow the wound to progress toward closure.
D. Presence of eschar: Eschar is a dry, leathery scab or crust that forms over a wound, usually composed of dead tissue. Like necrotic tissue, eschar must be debrided for healing to continue and does not indicate healthy tissue.
Correct Answer is D
Explanation
A. "The gait belt should be placed around the client's chest.": The gait belt should be positioned around the client’s waist, not the chest, to provide safe leverage and prevent injury. Placement over the chest can restrict breathing and increase the risk of falls or injury.
B. "The use of the gait belt still requires significant back strength.": Proper use of a gait belt allows the caregiver to assist the client safely without relying on excessive back strength. Emphasizing leverage and body mechanics reduces caregiver strain, so significant back strength is not required.
C. "The gait belt should remain on the client throughout the day.": The gait belt is intended for use only during transfers or ambulation. Leaving it on continuously can cause skin irritation and is unnecessary when the client is stationary.
D. "The gait belt should be placed over appropriate clothing.": Placing the gait belt over clothing provides comfort, prevents skin injury, and ensures a secure grip during ambulation. This statement reflects proper understanding of safe gait belt use.
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