Safety

The family of an older adult client is concerned about injuries from falls. The nurse providing discharge teaching would best minimize this risk by encouraging the family to perform which intervention? A. Keep walkways free of clutter since alteration in vision happens with aging. B. Discourage the client from wearing rubber-soled shoes. C. Place exposed extension cords under decorative carpet runners. D. Cover the kitchen's tiled floor with several scatter rugs.

A. Keep walkways free of clutter since alteration in vision happens with aging. (Rationale: Older adults are at risk for falls related to environmental hazards, such as scatter rugs, loose or loosely covered cords, and cluttered walkways. The use of rubber-soled shoes is appropriate. Other fall prevention in older adults focuses on strength/balance exercises and vitamin D supplements to improve bone health.)

Fall prevention in older adults should focus on which types of exercise? A. Strength building and balance B. Swimming and running C. Stretching and toning D. Brisk walking and tai chi

A. Strength building and balance (Rationale: Fall prevention in the older adults should focus on strength and balance exercises and vitamin D supplements to improve mobility and bone strength. Swimming and brisk walking are examples of aerobic exercise, while stretching is an example of a flexibility exercise.)

The nurse is caring for an older adult client on the medical unit admitted for diagnostic testing. The client is alert and oriented and lives independently. The client was wearing glasses upon admission. Which nursing intervention will be most effective in the prevention of falls for this client? A. using a gait belt each time the client ambulates B. ensuring the client's glasses are close by the bed C. placing a bed alarm on the bed D. moving the client to a room close to the nurse's station

B. ensuring the client's glasses are close by the bed (Rationale: This client does not require aggressive fall prevention measures since the client lives independently, is only having diagnostic testing, and is alert and oriented. Keeping the client's glasses close by will ensure the use of sensory appliances necessary to prevent falls.)

The older adult client is moving to another apartment. The nurse should encourage the client's family to take which action to reduce the older adult's risk of falling in the new home? A. Clear clutter in the walkways of the new home. B. Change the older adult's routine. C. Take walks outside. D. Use the stairs in the new home.

A. Clear clutter in the walkways of the new home. (Rationale: The nurse should recommend that the client's family ensure that walking paths and floors in the home are free of clutter, which is an environmental hazard that increases the risk of falls in the home. Changing routines, taking walks outside, and using the stairs will not reduce the risk of falling in the home.)

Nursing staff are trying to provide for the safety of an older adult with moderate dementia. The client is wandering at night and has trouble keeping her balance. She has fallen twice but has had no resulting injuries. Which action by the nurse is most appropriate? A. Move the client to a room near the nurse's station and install a bed alarm. B. Have the client sleep in a reclining chair across from the nurse's station. C. Help the client to bed and raise all four bedrails. D. Ask a family member to stay with the client at night.

A. Move the client to a room near the nurse's station and install a bed alarm. (Rationale: Using a bed alarm enables the staff to respond immediately if the client tries to get out of bed. Sleeping in a chair at the nurse's station interferes with the client's restful sleep and privacy. Using all four bedrails is considered a restraint and unsafe practice. It is not appropriate to expect a family member to stay all night with the client.)

A nurse is providing a fall prevention clinic for a group of older adults. What information should the nurse include? Select all that apply. A. Place grab bars in the shower and tub B. Have routine vision and hearing screenings C. Frequently change the furniture layout in the home D. Wear nonslip shoes or socks when walking E. Review medications routinely for side effects F. Use scatter rugs on hard wood surfaces.

A. Place grab bars in the shower and tub B. Have routine vision and hearing screenings D. Wear nonslip shoes or socks when walking E. Review medications routinely for side effects (Rationale: Grab bars in the shower and tub may decrease the chance of a fall on a slippery surface. Visual and hearing issues may contribute to falls. Medication interaction and side effects may increase the risk for falls, so medications should be reviewed. The older adult should wear proper nonskid footwear or socks when walking to help prevent falls. Changing the layout of the furniture in the home may increase the risk for falls because of items being in unfamiliar locations. Scatter rugs should not be used because they increase the risk for falls.)

Short-term use of restraints is permitted only in which situation? A. The client is imminently aggressive and a danger to the self or others. B. The client is noncompliant with treatment. C. The client wants to leave the hospital but there is no order to do so. D. The client is agitated and talkative.

A. The client is imminently aggressive and a danger to the self or others. (Rationale: Short-term use of restraints is permitted when the client is imminently aggressive and a danger to the self or others. Noncompliance with treatment, wanting to leave the hospital without an order to do so, and client agitation and talkativeness are not reasons to apply restraints.)

The nurse has done fall prevention teaching with the family of a client who is being discharged home. Which action by the client and family indicates that the teaching has been effective? A. eliminating home safety hazards B. encouraging an exercise regimen to strengthen muscles C. maintaining medication administration at regular times throughout the day, unless the client is sleeping D. ensuring adequate nutrition, including tea and complex carbohydrates

A. eliminating home safety hazards (Rationale: Falls in the home occur most frequently from hazards in the home, such as loose rugs, cluttered hallways, and power cords. The other choices do not address fall prevention.)

A nurse is assessing a client for the risk of falls. The nurse should obtain A. gait and balance information. B. the facility's restraint policy. C. the family's psychosocial history. D. the client's level of activity at home.

A. gait and balance information. (Rationale: Assessing the client's gait and balance helps determine the risk of falls. The facility's policy on restraints isn't relevant to a risk assessment for falls. Assessing the family's psychosocial history and determining the patient's home activity level are important but not as important as gait and balance in relation to the risk of falls.)

The nurse is caring for a client with a nasogastric tube and in mitt restraints. Which nursing action is required every 1 to 2 hours? A. Assist the client to the bathroom. B. Assess cognitive status. C. Offer the client sips of clear liquids. D. Remove restraints and assess skin and circulation.

D. Remove restraints and assess skin and circulation. (Rationale: Placing a client in any type of restraint is a controversial issue. Strict guidelines exist. The client in restraints must have the skin integrity and circulation assessed every 1-2 hours. It is also appropriate to massage the area and provide range of motion exercises. On a regular basis, the client would be offered to use a bedpan or ambulate to the bathroom and the nurse would assess the cognitive status. A client with a nasogastric tube would not be offered fluids.)