When caring for the elderly the nurse must implement which measure for client safety?
Keep the environment free of obstacles
Raise the bed for client ease upon exiting
Avoid bright lighting
Keep linens away from nursing uniform
The Correct Answer is A
A. This is essential to prevent falls, which are a common and serious risk for the elderly. A clutter-free environment allows for safe and easy mobility.
B. Raising the bed, can actually increase the risk of falls if the bed is too high for safe exit.
C. Bright lighting can cause glare and visual discomfort for elderly individuals, especially those with age- related eye conditions such as cataracts or macular degeneration. However, adequate lighting is crucial for safety. The key is to provide sufficient lighting that is evenly distributed and free of glare or harsh shadows, which can help prevent falls.
D. While keeping linens away from the nursing uniform is good practice for infection control, it does not directly relate to the immediate physical safety of the client in the same way that a clear environment does.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
D. Metabolic alkalosis is characterized by an increased pH (alkalosis) and an increased HCO3. In this case, the pH is elevated (7.5), indicating alkalosis, which supports metabolic alkalosis. The HCO3 is elevated at 40 mEq/L, which further supports metabolic alkalosis. The PaCO2 is normal or slightly low (36 mmHg), which can occur as a compensatory response to metabolic alkalosis.
A. Respiratory alkalosis is characterized by an increase in pH (alkalosis) and a decrease in PaCO2 (hypocapnia). In this scenario, the pH is elevated (7.5), which indicates alkalosis. The PaCO2 is 36 mmHg, which is within the normal range (35-45 mmHg) but slightly on the lower side (slight hypocapnia). The HCO3 is elevated at 40 mEq/L, which suggests a compensatory response by the kidneys to retain bicarbonate to counteract the alkalosis.
B. Respiratory acidosis is characterized by a decrease in pH (acidosis) and an increase in PaCO2 (hypercapnia). In this case, the pH is elevated (7.5), indicating alkalosis, which contradicts respiratory acidosis. The PaCO2 is 36 mmHg, which is normal or slightly low, not high as expected in respiratory acidosis. The elevated HCO3 (40 mEq/L) suggests a compensatory metabolic response to the alkalosis, not to acidosis.
C. Metabolic acidosis is characterized by a decreased pH (acidosis) and a decreased HCO3. In this scenario, the pH is elevated (7.5), indicating alkalosis, which contradicts metabolic acidosis. The HCO3 is elevated at 40 mEq/L, indicating metabolic alkalosis rather than metabolic acidosis.
Correct Answer is B
Explanation
B. This is the initial phase of the nurse-client relationship where the individuals first meet. It is characterized by establishing rapport, clarifying roles, setting goals, and developing an agreement or contract for the relationship.
A. This phase occurs towards the end of the nurse-client relationship when goals have been achieved or the relationship is ending for other reasons. It involves summarizing, evaluating progress, and saying goodbye.
C. This phase follows the orientation phase. It is characterized by actively working together to achieve mutually agreed upon goals. During this phase, the nurse and client explore issues, develop and implement solutions, and evaluate progress towards goals.
D. This phase occurs before the nurse and client meet formally. It involves gathering information about the client from various sources, such as medical records or other healthcare professionals.
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