An older client is observed having difficulty moving from a ...

[rl]

An older client is observed having difficulty moving from a sitting to standing position, and has an unsteady gait. What should the nurse assess in this client to promote home safety?
 
  1. Presence of grab bars in the bathroom
  2. Absence of scatter rugs on the floors
  3. Correct use of cane to ambulate
  4. Ability to stand in place for a minute before ambulating
  5. Alcohol use with prescribed medications

Question 2

The nurse is admitting an older client to the care area. What can the nurse do to promote a safe environment for the client?
 
  1. Keep clutter to a minimum in the client's room.
  2. Have the client wear terry-cloth slippers.
  3. Provide adequate lighting.
  4. Turn off alarms to reduce noise.

[jharrington11]

Answer to Question 1

Correct Answer: 1, 2, 3
Rationale 1: For home safety, it would be beneficial for the client with difficulty moving from a sitting to standing position to have grab bars in the bathroom.
Rationale 2: For home safety, it would be beneficial for the client with an unsteady gait not to have scatter rugs on the floor.
Rationale 3: For home safety, it would be beneficial for the client with an unsteady gait to be able to use a cane correctly.
Rationale 4: The ability to stand in place for a minute before ambulating would be applicable if the client were demonstrating signs of orthostatic hypotension.
Rationale 5: The use of alcohol with prescribed medications would be beneficial if the client were prescribed sedatives or hypnotics.

Answer to Question 2

Correct Answer: 3
Rationale 1: The environment should be clutter-free because any clutter can cause the client to fall.
Rationale 2: Wearing terry-cloth slippers would allow the client to fall. The client should have rubber skid-resistant soles.
Rationale 3: Providing adequate lighting will help prevent the client from falling.
Rationale 4: Noise should be kept to a minimum, but turning off alarms would endanger a client.

[rl]

TYSM

[okolip]

Excellent