An 88-year-old woman is admitted to the hospital with a diagnosis of pneumonia. She has a his-tory of hypertension and congestive heart failure and is on a total of five different medications for these chronic conditions
The nurse caring for the woman develops a care plan that includes the diagnosis Risk for Falls. A priority nursing intervention for this client is to:
a. perform a fall assessment.
b. keep all of the side rails up on the client's bed at nighttime.
c. place the client on bed rest so that she does not fall.
d. assess the client's dietary intake for cal-cium adequacy.
ANS: A
Completing a fall assessment will enable the nurse to identify and correct the risk factors for this patient. Side rails have not been found to be effective in keeping a client in bed and may actually lead to injury. Maintaining a patient on bed rest can lead to deconditioning and actually contrib-ute to falls. Assessing the client's dietary intake of calcium is a good intervention for this age group, but it is not a priority and will not prevent falls.
You might also like to view...
When assessing a woman for menopausal discomforts, the nurse expects the woman to describe the most frequently reported discomfort, which is
a. Headaches b. Hot flashes c. Mood swings d. Vaginal dryness with dyspareunia
The nurse is confident that the client who chooses to take red rice yeast daily for dyslipidemia has an understanding of its possible side effects when the client: Select all that apply
a. has regular laboratory work to monitor cholesterol levels b. shows caution by slowly rising from the chair c. states, "If I start noticing muscle pain, I'll stop taking the pills" d. schedules regular, yearly glaucoma screenings e. takes the supplement with breakfast and dinner
The nurse is attempting to seek clarification from the client. What are examples of questions that the nurse can ask the client to seek clarification?
1 . "Do you smoke?" 2 . "Tell me more about it." 3 . "Explain that to me." 4 . "What do you mean by walking with the dog?" A) 1, 2, 3 B) 1, 2, 4 C) 1, 3, 4 D) 2, 3, 4
The nurse is reviewing the laboratory results for a patient being evaluated for trouble with passing urine. The urinalysis shows tubular epithelial cells on microscopic examination. How does the nurse interpret this findings?
a. The obstruction is resolving. b. The obstruction is prolonged. c. Glomerular filtration rate is reduced. d. Glomerular filtration rate is adequate.