a nurse is developing a plan of care for an older adult who is at risk for falls which of the following actions should the nurse include
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Nursing Elites

ATI RN

RN ATI Capstone Proctored Comprehensive Assessment 2019 B with NGN

1. A nurse is developing a plan of care for an older adult who is at risk for falls. Which of the following actions should the nurse include?

Correct answer: A

Rationale: The correct action for the nurse to include in the plan of care for an older adult at risk for falls is to lock beds and wheelchairs when not in use. This measure is crucial for preventing falls and ensuring patient safety in healthcare settings. Administering sedatives at bedtime (Choice B) is not recommended as it does not address the underlying risk factors for falls and may increase the risk of injury. Providing information about home safety checks (Choice C) is important for fall prevention in the home environment but is not directly related to healthcare settings. Teaching balance and strengthening exercises (Choice D) is beneficial for fall prevention but may not be suitable for all older adults at risk for falls, especially in acute care settings.

2. A school nurse is developing a teaching plan about testicular cancer for a group of clients. Which of the following information should the nurse include in the teaching?

Correct answer: C

Rationale: The correct answer is C because testicles should be uniform in consistency when performing a self-exam, and any lumps or abnormalities should be reported. Choice A is incorrect as testicular self-examinations should be performed monthly, not weekly. Choice B is incorrect because the epididymis should be included in the examination. Choice D is incorrect because a warm shower helps relax the scrotum, making the exam easier to perform.

3. How should the nurse manage the client's pain if a client with a history of substance abuse is requesting pain medication?

Correct answer: B

Rationale: When a client with a history of substance abuse requests pain medication, the nurse should first assess the patient's pain level. It is important to determine the nature and intensity of the pain before administering any medication to ensure appropriate pain management. Administering medication without assessing the pain level can lead to unnecessary drug administration or inadequate pain relief. Administering a placebo would be unethical and ineffective. Refusing to give any medication without proper assessment can compromise the client's comfort and recovery. Therefore, the correct approach is to assess the patient's pain level first before deciding on the most suitable pain management intervention.

4. A nurse is preparing an in-service about family violence for a group of newly licensed nurses. Which of the following statements should the nurse include in the teaching?

Correct answer: C

Rationale: The correct answer is C because the risk of homicide increases significantly when a victim decides to leave an abusive relationship. This is a crucial point to emphasize in educating healthcare professionals about family violence. Choice A is incorrect because perpetrators often do not acknowledge their behavior as abnormal. Choice B is incorrect as victims of partner violence are at greater risk for chronic, not acute, diseases. Choice D is incorrect as the level of violence tends to escalate rather than decrease over time in abusive relationships.

5. A case manager at an assisted living facility is reviewing the use of complementary health practices by several clients. Which of the following actions should the case manager plan to take?

Correct answer: B

Rationale: The correct answer is B. Tai chi is a recognized complementary health practice for stress reduction. Scheduling time for a new client to continue tai chi practice aligns with supporting holistic care. Choice A is incorrect because reporting a client's use of echinacea as a contraindication to aspirin therapy is not necessary without further context or evidence of interactions. Choice C is wrong because yoga can indeed be effective in reducing manifestations of menopause. Choice D is also incorrect because while cranberry juice is known to help prevent urinary tract infections, it is not typically used to treat existing infections.

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