which of the following statements from a client may indicate that they are at a higher risk for a fall

NCLEX-PN

Safe and Effective Care Environment Nclex PN Questions

1. Which of the following statements from a client may indicate that they are at a higher risk for a fall?

A. "I would like to get out of bed but would like to put on my non-skid socks first."?
B. "Can you make sure the two bedrails are raised before leaving the room?"?
C. "I think I'm ready to walk a longer distance with the cane today."?
D. "I need to get out of bed to go to the bathroom now. I cannot find my glasses but cannot wait."?

Correct answer: D

Rationale: The correct answer is 'I need to get out of bed to go to the bathroom now. I cannot find my glasses but cannot wait.' This statement indicates that the client is in a hurry and unable to find their glasses, which could increase the risk of a fall due to impaired vision. Choice A about putting on non-skid socks shows the client's awareness of fall prevention, reducing the risk. Choice B demonstrates the client's request for bedrails to be raised, which is a safety measure, reducing the risk as well. Choice C suggests the client's readiness to walk a longer distance with a cane, indicating progress in mobility but not necessarily a higher fall risk.

2. A client who is immobilized secondary to traction is complaining of constipation. Which of the following medications should the nurse expect to be ordered?

A. Advil
B. Anasaid
C. Clinocil
D. Colace

Correct answer: D

Rationale: Colace is a stool softener that acts by pulling more water into the bowel lumen, making the stool soft and easier to evacuate. In the given scenario of constipation in an immobilized client, a stool softener like Colace is the appropriate choice to help facilitate bowel movements. Advil and Anasaid are nonsteroidal anti-inflammatory drugs (NSAIDs) used for pain relief, not for constipation. Clinocil is not a recognized medication for constipation relief.

3. Which statement about clinical pathways is inaccurate?

A. They require daily updates.
B. They illustrate the expected client response to their diagnosis.
C. The objective is improvement or discharge from the facility.
D. They are evidence-based.

Correct answer: A

Rationale: The correct answer is that clinical pathways do not necessarily require daily updates. Clinical pathways can be customized to be updated daily, weekly, or at other intervals based on patient needs and facility protocols. Choice A is inaccurate as daily updates are not always mandatory for clinical pathways. Choices B, C, and D are accurate features of clinical pathways: they depict the expected client response to the diagnosis, aim for improvement or discharge, and are grounded in evidence-based practices to ensure optimal care.

4. How does cancer affect pain tolerance in elderly clients?

A. Remain constant.
B. Decrease.
C. Increase.
D. Cancer has no impact on pain tolerance in elderly clients.

Correct answer: B

Rationale: Pain tolerance in elderly clients with cancer is likely to decrease due to factors such as diminished adaptative capacity, increased physical discomfort, and the psychological impact of the disease. Cancer is known to cause various physical and emotional stressors that can lower the pain threshold, leading to a decrease in pain tolerance. Choices A, C, and D are incorrect because cancer and its associated effects typically result in a decrease in pain tolerance rather than remaining constant, increasing, or having no impact.

5. An Asian family has an elderly member with the latest stage of Alzheimer's disease. The physician has recommended placement in a long-term care facility, but the family refuses. Which of the following is an appropriate response by the nurse?

A. "You really need to listen to what the physician says."?
B. "You will get too tired to take care of him at home."?
C. "What can I do to assist you to care for him at home?"?
D. "You are too busy to be taking care of an elderly person."?

Correct answer: C

Rationale: The correct answer is, "What can I do to assist you to care for him at home?"? This response shows cultural sensitivity and respect for the family's values. In many Asian cultures, there is a strong tradition of caring for elders at home rather than in a long-term care facility. By offering assistance to the family in caring for their elderly member at home, the nurse shows understanding and support. Choices A, B, and D are incorrect because they do not acknowledge or respect the family's cultural beliefs and values regarding caring for elderly family members.