What is an important strategy for fall prevention in older adults?

Encouraging regular exercise and physical activity.

Removing all rugs and carpets from the home.

Encouraging the use of medications that cause drowsiness.

Limiting social activities and outings.

Answer and Explanation

The Correct Answer is A

A.   This is an important strategy for fall prevention. Regular exercise helps improve strength, balance, flexibility, and coordination, which can significantly reduce the risk of falls. Physical activity also enhances overall health and mobility, making it easier for older adults to perform daily tasks safely.
B.   Removing all rugs and carpets can reduce tripping hazards, but it’s not always practical or aesthetically pleasing. Instead, it’s advisable to secure rugs with non-slip backing and ensure they are not placed in high-traffic areas. Therefore, while removing some rugs can be helpful, not all should be removed.
C.   Medications that cause drowsiness can increase the risk of falls by impairing balance, coordination, and alertness. Older adults should be encouraged to discuss their medications with healthcare providers to minimize side effects that may contribute to fall risks.
D.   In fact, social engagement can promote physical activity and mental well-being, both of which can help reduce fall risk. Limiting social activities can lead to isolation, which may negatively impact an older adult's physical and emotional health.

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Correct Answer is C

Explanation

A. This statement pertains to the client's current state but does not represent an intervention taken by the nurse. It would be more appropriate for documentation in a narrative or assessment section rather than the intervention component.
B. This entry describes an outcome or finding related to the client’s condition rather than an intervention. While it is important data, it does not reflect an action taken by the nurse and thus would not be included in the intervention section.
C. It clearly describes a specific action taken by the nurse (administering medication) in response to the problem (nausea and vomiting). It directly addresses the client's needs and reflects an intervention aimed at treating the identified problem.
D. This statement indicates the problem or symptom that the client is experiencing but does not describe an intervention. While it is critical information for understanding the client’s condition, it belongs in the problem or assessment section rather than the intervention component.

A. Elevate the head of the client's bed to 45° during meals. B. Instruct the client to tilt their head back while swallowing. C. Provide the client with oral hygiene. D. Turn on the television for the client during meals.

Correct Answer is A

Explanation

A. Elevating the head of the bed during meals can help prevent aspiration by allowing gravity to assist in keeping food and liquids in the esophagus rather than the airway. This position reduces the risk of aspiration pneumonia significantly for clients who may have swallowing difficulties.
B. Tilting the head back while swallowing can increase the risk of aspiration, as it can cause food or liquids to flow into the airway rather than the esophagus. Proper swallowing techniques usually involve tilting the head slightly forward or maintaining a neutral position.
C. While good oral hygiene is essential for overall health and can help reduce the risk of aspiration pneumonia by minimizing bacteria in the mouth, it is not a direct action during meal times that prevents aspiration. Oral hygiene is important but should be part of a comprehensive care plan.
D. Distractions during meals, such as watching television, can lead to decreased attention to swallowing and increase the risk of aspiration. It can divert the client’s focus from the act of eating, making it harder for them to manage their swallowing effectively.

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What is an important strategy for fall prevention in older adults?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is documenting in a client's health record using the problem-intervention-evaluation charting model (PIE). Which of the following information should be included in the intervention component?

Correct Answer is C

Explanation

A nurse is caring for a client who has dementia. Which of the following actions should the nurse take to reduce the client's risk of aspiration pneumonia?

Correct Answer is A

Explanation

A nurse is assisting with the plan of care for a client who is immobile and is experiencing urinary retention. The nurse should plan to monitor the client for which of the following?

A nurse is assisting with teaching a class about physiological changes to hearing in older adult clients. Which of the following should the nurse include?

A nurse is assisting a client who had a lower extremity amputation with a bath. Which of the following actions should the nurse take?

A nurse is caring for a client who has phantom limb pain. The nurse should identify the client is experiencing which type of pain?

A nurse is caring for a client who has urinary incontinence. Which of the following actions should the nurse take?

A nurse is assisting with teaching a newly licensed nurse about pain. Which of the following is an example of acute pain?

A nurse is assisting with teaching a class about alternative medicine. The nurse should include that which of the following practices is based on a balance of the body, mind, and spirit to prevent disease?

A nurse is completing a SOAP note in a client's chart. In which of the following sections should the client's vital signs be documented?