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?

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.

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

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

Answer and Explanation

The Correct Answer is A

Choice A reason: Completing the fall risk survey provides a comprehensive assessment of the client's fall risk, considering all factors.

Choice B reason: Informing the client that falls occur more often in the hospital does not complete the assessment.

Choice C reason: Recording a minimal risk based solely on the client's statement may not accurately reflect the true fall risk.

Choice D reason: Placing the client on high fall risk protocol based on age alone is not appropriate without a complete assessment.

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Correct Answer is D

Explanation

Choice A reason: Ignoring the client can escalate the behavior, as individuals with antisocial behavior may act out more to gain attention.

Choice B reason: Introducing him to the newly admitted client and asking him to join the conversation can disrupt the admission process and does not address the client's behavior appropriately.

Choice C reason: Encouraging him to go to the nurse's station and talk with another nurse may be an option, but it does not directly address the client's need for immediate attention.

Choice D reason: Informing him that the nurse is busy and will talk to him later sets clear boundaries and allows the nurse to complete the admission process without disruption.

A. Keep the room brightly lit while providing care. B. Minimize verbal interaction with the client. C. Monitor for change in speech. D. Avoid dropping side rails or abruptly closing the door. E. Report any change in level of consciousness.

Correct Answer is ["C","D","E"]

Explanation

Choice A reason: Keeping the room brightly lit while providing care may help with orientation but is not a specific instruction related to stroke care.

Choice B reason: Minimizing verbal interaction with the client is not advisable. Communication is essential in assessing the client's neurological status.

Choice C reason: Monitoring for change in speech is important as speech difficulties can indicate a worsening of the stroke or other neurological issues.

Choice D reason: Avoiding dropping side rails or abruptly closing the door helps minimize unnecessary stimulation and agitation, which can be beneficial for a client experiencing a stroke.

Choice E reason: Reporting any change in level of consciousness is critical as it can indicate changes in the client's condition that require immediate medical attention.

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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 psychiatric nurse is talking to a newly admitted client when another male client, who is diagnosed with antisocial behavior, intrudes on the conversation and tells the nurse, "I have to talk to you right now! It is very important!" How should the nurse respond to this client?

Correct Answer is D

Explanation

A client is admitted during the acute phase of a stroke. The nurse observes that the client is restless and unable to follow instructions. Which instruction(s) should the nurse provide the unlicensed assistive personnel (UAP) who is assisting with the care of the client? Select all that apply.

Correct Answer is ["C","D","E"]

Explanation

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