The nurse assesses an older adult client’s ability to perform activities of daily living (ADLs). When observing the client ambulate, the nurse notes that the client’s posture is upright, and the gait is smooth and steady. Which action should the nurse take next?
Determine the client’s activity tolerance.
Teach the client to shorten the stride to prevent falls.
Initiate a fall risk protocol for the client.
Record the client’s ability to perform ADLs safely.
The Correct Answer is D
Choice A rationale
Determining the client’s activity tolerance is important but should follow the initial assessment of the client’s ability to perform ADLs safely.
Choice B rationale
Teaching the client to shorten the stride to prevent falls is not necessary if the client’s gait is smooth and steady. This intervention is more appropriate for clients with gait instability.
Choice C rationale
Initiating a fall risk protocol for the client is not necessary if the client’s gait is smooth and steady. This protocol is more appropriate for clients with a higher risk of falls.
Choice D rationale
Recording the client’s ability to perform ADLs safely is the next appropriate action. This documentation is essential for the care plan and ensures that the client’s current status is accurately reflected.
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Correct Answer is D
Explanation
Choice A rationale
Recording a palpable systolic pressure of 90 mm Hg without further action would likely underestimate the true systolic pressure. The nurse should inflate the cuff to a higher pressure to obtain an accurate measurement.
Choice B rationale
Releasing the manometer valve immediately would lead to deflating the cuff and potentially missing the opportunity to obtain an accurate blood pressure measurement.
Choice C rationale
Documenting the absence of the radial pulse is important, but it is also crucial to ensure that blood pressure measurements are obtained correctly. Further action is needed to obtain an accurate measurement.
Choice D rationale
Inflating the blood pressure cuff to 120 mm Hg is the correct action. When the radial pulse becomes unpalpable during cuff inflation, the cuff should be inflated to a higher pressure (usually 20-30 mm Hg above the point where the radial pulse disappears) and then slowly deflated while palpating for the return of the radial pulse.
Correct Answer is B
Explanation
Choice A rationale
Administering a PRN sedative prescription should not be the first intervention as it does not address the underlying cause of the client’s confusion and wandering.
Choice B rationale
Leaving the door to the client’s room open slightly can help reduce feelings of isolation and anxiety by allowing the client to see and hear staff members as they pass by.
Choice C rationale
Applying wrist restraints should be a last resort and not the first intervention for managing wandering behavior.
Choice D rationale
Providing a back rub at bedtime may help promote relaxation but does not directly address the issue of wandering.