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 ["A","C","D"]

Explanation

Choice A reason: Oatmeal is high in fiber and helps soften stools, making it a good option for someone with hemorrhoids.

Choice B reason: Bacon slices are not high in fiber and are not recommended.

Choice C reason: Raisin bran muffins are high in fiber and beneficial for managing hemorrhoids.

Choice D reason: Raspberries are high in fiber and are a good choice for a high-fiber diet.

Choice E reason: Scrambled eggs do not contain fiber and are not particularly beneficial for increasing fiber intake.

A. Catheter tubing. B. The client's bed. C. Urinary meatus. D. Client's bladder.

Correct Answer is A

Explanation

Choice A reason: The catheter tubing is the most likely reservoir for the infection as it can harbor bacteria and introduce them into the urinary tract when not managed properly.

Choice B reason: The client's bed is an unlikely reservoir for the infection as it does not have direct contact with the urinary system.

Choice C reason: The urinary meatus is part of the normal flora but is not the primary reservoir for the infection in this scenario.

Choice D reason: The client's bladder is the site of the infection, not the reservoir that introduced the bacteria.

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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

A client with hemorrhoids asks for information about a high fiber diet. Which breakfast menu item(s) should the nurse suggest? Select all that apply.

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

Explanation

A client's catheter bag was left on the client's bed for a prolonged period of time, and the client develops a urinary tract infection (UTI). In evaluating the cause of the infection, which should the nurse identify as the infection reservoir?

Correct Answer is A

Explanation

After inflating a blood pressure cuff and releasing the valve, the nurse hears silence followed by a Korotkoff sound. Which action should the nurse take next?

After a scheduled downtime, the computer documentation system fails to restart. Which action should the nurse take first?

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