While the nurse is assessing an older client's fall risk, the client reports living at home alone and never falling. Which action should the nurse take?

Record a minimal risk for falls, documenting the client's statement

Place the client on a high fall risk protocol because of advanced age.

Continue to obtain client data needed to complete the fall risk survey.

Inform the client that falls occur more often in the hospital than at home.

Answer and Explanation

The Correct Answer is C

A. Relying solely on the client’s statement is insufficient for determining fall risk. A more comprehensive assessment is needed.
B. Advanced age alone does not automatically categorize a client as high risk for falls. A complete assessment should be used to evaluate risk.
C. A thorough assessment, including a fall risk survey, is essential to accurately determine the client’s risk for falling. The fact that the client has never fallen does not automatically categorize them as low risk.
D. Informing the client that falls occur more often in the hospital than at home does not address the need for an individualized risk assessment.

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Correct Answer is D

Explanation

A. A video on breast self-examination is useful but does not ensure engagement.
B. Morbidity data for all races does not focus on African-American women specifically.
C. A listing of community members may not ensure meaningful participation.
D. Involving community leaders fosters trust and cultural relevance, increasing program effectiveness.

A. Position bedside table so the client can lean across it. B. Raise head of bed until to a 90 degree angle. C. Encourage rest until the analgesic becomes effective. D. Place bed in a reverse trendelenburg position.

Correct Answer is A

Explanation

A. Position bedside table so the client can lean across it. Clients with pancreatitis often find relief from pain by sitting up and leaning forward. This position helps alleviate the pressure on the pancreas and can reduce pain.

B. Raise head of bed to a 90-degree angle. Raising the bed too high may increase discomfort for clients with pancreatitis. The more comfortable position is typically sitting up but leaning forward.

C. Encourage rest until the analgesic becomes effective. While rest is important, positioning the client to alleviate pain should take priority in this situation.

D. Place bed in a reverse Trendelenburg position. This position is typically used for patients with cardiovascular or abdominal issues but is not the most effective for managing pancreatitis pain.

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While the nurse is assessing an older client's fall risk, the client reports living at home alone and never falling. Which action should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse has received funding to design a health promotion project for African-American women who are at risk for developing breast cancer. Which resource is most important in designing this program?

Correct Answer is D

Explanation

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Correct Answer is A

Explanation

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