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

Answer and Explanation

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.

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Correct Answer is A

Explanation

A. This is the most direct and appropriate question to assess for dysuria. Dysuria is characterized by pain, discomfort, or burning sensation during urination. Asking this question helps the nurse to directly assess if the client is experiencing these symptoms.

B. This question is more relevant for assessing urinary frequency rather than dysuria. It is important for assessing other urinary symptoms but does not specifically address the characteristic pain or discomfort associated with dysuria.

C. This question is pertinent for assessing urinary retention or incomplete emptying of the bladder, which are different concerns from dysuria. It evaluates the client's perception of bladder emptying rather than pain or discomfort during urination.

D. This question is more relevant for assessing urinary hesitancy or urgency, which are related to bladder function but are not specific to dysuria. It addresses issues with urine flow dynamics rather than pain or discomfort during urination.

A. Monitoring intake and output B. Providing good mouth and skin care C. Obtaining daily weights D. Assessing level of consciousness E. Administering a loop diuretic

Correct Answer is ["A","B","C","D"]

Explanation

A. Monitoring intake (fluids taken orally or intravenously) and output (urine, vomitus, diarrhea) helps assess fluid balance and hydration status. It is essential in clients with vomiting and diarrhea to prevent dehydration or fluid overload.

B. Vomiting and diarrhea can lead to dehydration and electrolyte imbalances, which may affect the skin and oral mucosa. Providing good mouth care (e.g., oral hygiene, hydration) and skin care (e.g., gentle cleansing, moisturizing) helps maintain comfort and prevent complications such as skin breakdown.

C. This may be appropriate depending on the severity of the client's condition and the healthcare provider's orders. Daily weights help monitor fluid balance and assess for changes in hydration status. However, in acute cases of vomiting and diarrhea, more frequent weights or other assessments of fluid status may be necessary.

D. Assessing the client's level of consciousness is important to monitor for signs of dehydration or electrolyte disturbances, which can affect neurological function. Changes in level of consciousness may indicate worsening dehydration or other complications that require prompt intervention.

E. Loop diuretics are medications used to increase urine output by inhibiting sodium reabsorption in the kidneys. However, they are not indicated for treating vomiting and diarrhea. In fact, administering diuretics could exacerbate fluid and electrolyte imbalances in a client who is already experiencing fluid loss through vomiting and diarrhea

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When caring for the elderly the nurse must implement which measure for client safety?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is assessing the client for the presence of dysuria. The nurse should ask: "Do you:

Correct Answer is A

Explanation

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Correct Answer is ["A","B","C","D"]

Explanation

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