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. "A fever may be an indicator that the inflammation has become systemic.": Fever is a body’s non-modifiable response to infection and inflammation. While important for identifying systemic involvement, the client cannot directly modify this defense mechanism.
B. "A balanced diet helps your immune system function properly.": Nutrition is a modifiable factor that supports the immune system by providing essential vitamins, minerals, and proteins needed for immune cell production and function. Clients can take direct action through diet to enhance infection prevention.
C. "Your skin acts as a barrier to microorganisms and helps prevent injury.": Skin integrity is a natural, non-modifiable defense mechanism. While clients can care for their skin, its barrier function is inherently physiological and not directly alterable.
D. "Tears reduce particles entering the eye, reducing the number of organisms.": Tear production is a natural defense mechanism. Although hygiene can support eye health, the production and function of tears are not directly modifiable by the client.
Correct Answer is B
Explanation
A. By focusing on medical diagnoses: Limiting a concept map to medical diagnoses restricts the nurse’s perspective and does not fully engage critical thinking. Concept maps integrate multiple aspects of patient care, including psychosocial, physiological, and nursing considerations, rather than focusing solely on diagnoses.
B. By examining interrelationships: Concept maps visually display the connections among patient problems, interventions, and outcomes, helping nurses identify patterns and prioritize care. Examining these interrelationships promotes deeper understanding, clinical reasoning, and the ability to anticipate complications. It enhances critical thinking and holistic patient care.
C. By following a linear approach: Concept maps are nonlinear tools that allow flexible exploration of complex patient situations. A strictly linear approach limits the ability to see connections and interactions, reducing opportunities for critical analysis.
D. By reducing assessment time: Concept maps do not shorten assessment but instead organize and synthesize data. Their value lies in improving understanding and decision-making rather than accelerating the assessment process.
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