The nurse notes that an elderly client has a history of osteoporosis. What safety measure should the nurse prioritize for this client?
Fall prevention
Pressure injury prevention
Cognitive impairment prevention
Functional decline prevention
The Correct Answer is A
Choice A reason: Fall prevention is the most important safety measure for an elderly client with osteoporosis, as falls can result in fractures and other complications. The nurse should assess the client's risk factors for falls, such as impaired vision, balance, or mobility, and implement interventions to reduce them, such as providing adequate lighting, removing clutter, and using assistive devices.
Choice B reason: Pressure injury prevention is also important for an elderly client, but not as crucial as fall prevention for a client with osteoporosis. Pressure injuries are caused by prolonged pressure on the skin, especially over bony prominences. The nurse should reposition the client frequently, use pressure-relieving devices, and monitor the skin for signs of breakdown.
Choice C reason: Cognitive impairment prevention is not a specific safety measure for an elderly client with osteoporosis, although it may affect the client's ability to follow instructions and adhere to treatment. Cognitive impairment may be caused by various factors, such as dementia, delirium, or medication side effects. The nurse should assess the client's mental status, provide orientation and stimulation, and manage any underlying causes.
Choice D reason: Functional decline prevention is not a specific safety measure for an elderly client with osteoporosis, although it may affect the client's quality of life and independence. Functional decline may be caused by various factors, such as pain, weakness, or depression. The nurse should encourage the client to participate in physical and occupational therapy, promote self-care activities, and provide emotional support.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A reason: A teacher who notices a mole change but doesn't have time to see a dermatologist is not in a state of wellness. A mole change could indicate skin cancer, which is a serious health problem that requires prompt medical attention. Ignoring or delaying the diagnosis and treatment of skin cancer could compromise the teacher's physical and emotional well-being.
Choice B reason: A fitness trainer who is struggling to cope with the death of her mother is not in a state of wellness. The death of a loved one is a major life stressor that can affect the fitness trainer's mental and emotional health. Grieving is a normal and healthy process, but it can also interfere with the fitness trainer's daily functioning and quality of life. The fitness trainer may need professional help or support from family and friends to cope with the loss.
Choice C reason: A hospice client who is comfortable and at peace with dying is in a state of wellness. Wellness is not only the absence of disease, but also the presence of positive health behaviors and attitudes. A hospice client who is comfortable and at peace with dying has accepted the reality of their condition and has made peace with themselves and others. The hospice client may also receive palliative care, which aims to relieve pain and suffering and improve the quality of life for terminally ill patients and their families.
Choice D reason: A type 1 diabetic who gives himself extra insulin so he can eat cookies is not in a state of wellness. A type 1 diabetic who gives himself extra insulin so he can eat cookies is engaging in unhealthy and risky behavior that could harm his physical health. Extra insulin could cause hypoglycemia, which is a condition where the blood sugar level drops too low and can lead to seizures, coma, or death. Eating cookies could also increase the blood sugar level and contribute to complications such as nerve damage, kidney damage, or cardiovascular disease. A type 1 diabetic who wants to eat cookies should follow a balanced diet and monitor his blood sugar level regularly.
Correct Answer is B
Explanation
Choice A reason: This is not the correct answer because offering to notify the health care provider after morning rounds are completed is not the first action that the critically thinking nurse should take. The nurse should act promptly and advocate for the patient's pain management needs, rather than delaying the communication with the health care provider.
Choice B reason: This is the correct answer because exploring other options for pain relief is the first action that the critically thinking nurse should take. The nurse should assess the patient's pain level, location, quality, and contributing factors, and use a multimodal approach to pain management that includes pharmacological and non-pharmacological interventions, such as ice, heat, distraction, relaxation, or massage.
Choice C reason: This is not the correct answer because discussing the surgical procedure and reason for the pain is not the first action that the critically thinking nurse should take. The nurse should focus on alleviating the patient's pain, rather than educating the patient about the surgery. The nurse can provide information and reassurance to the patient after the pain is controlled.
Choice D reason: This is not the correct answer because explaining to the patient that nothing else has been ordered is not the first action that the critically thinking nurse should take. The nurse should not dismiss the patient's pain or imply that the patient has no other options for pain relief. The nurse should collaborate with the patient and the health care provider to find the best pain management plan for the patient.
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