The RN performs an admission assessment and determines the client is a fall risk. What is a priority nursing intervention for this client?
Provide a walker.
Place a chair on either side of the bed.
Provide a cane.
Place a fall risk wrist band on the client.
The Correct Answer is D
This is because a fall risk wristband alerts the staff and other caregivers that the client is at risk of falling and needs extra precautions and supervision. A walker, a cane, or a chair on either side of the bed are not priority interventions for a fall risk client, as they do not address the root cause of the problem or prevent potential falls.
Choice A is wrong because a walker may not be appropriate for the client’s condition or mobility level, and it may pose a tripping hazard if not used correctly.
Choice B is wrong because placing a chair on either side of the bed may limit the client’s access to the bed or the bathroom, and it may also create clutter and obstruction in the room.
Choice C is wrong because a cane may not provide enough stability or support for the client, and it may also be difficult to use in narrow spaces or on slippery surfaces.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Increasing regular weight-bearing activities can help prevent osteoporosis by stimulating bone formation and improving muscle strength. Weight-bearing activities are those that make your bones and muscles work against gravity, such as walking, jogging, dancing, or lifting weights.
Choice A is wrong because protecting the client’s bones with strict bedrest can actually increase the risk of osteoporosis by reducing bone density and muscle mass. Bedrest should be avoided unless medically necessary.
Choice B is wrong because providing the client with assisted range of motion exercises twice daily is not enough to prevent osteoporosis. While these exercises can help maintain joint mobility and flexibility, they are not weight bearing and do not stimulate bone formation.
Choice C is wrong because decreasing the amount of calcium in the client’s diet can also increase the risk of osteoporosis. Calcium is an essential mineral for bone health and adults need 700mg a day, which can be obtained from foods such as dairy products, leafy green vegetables, tofu, and dried fruit. Vitamin D is also important for bone health as it helps the body absorb calcium.
Correct Answer is B
Explanation
This is because the nurse should not make assumptions about the family’s functionality based on their history or situation, but rather gather more information to identify their strengths and needs.
Choice A is wrong because it implies that the teenager is a problem and the mother is incapable of managing him, which is disrespectful and judgmental.
Choice C is wrong because it assumes that the mother is stressed and needs coping skills, which may not be true.
Choice D is wrong because it suggests that the mother is financially dependent on her son, which is not relevant to the question.
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