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 C
Explanation
Choice A rationale
Removing dentures or other oral appliances may help prevent airway obstruction but is not the most critical intervention for a client with severe obstructive sleep apnea (OSA).
Choice B rationale
Elevating the head of the bed to a 45-degree angle can help improve airway patency but is not as effective as applying the positive airway pressure device.
Choice C rationale
Applying the client’s positive airway pressure device (CPAP or BiPAP) is the most important intervention to maintain airway patency and prevent respiratory compromise in a client with severe obstructive sleep apnea (OSA).
Choice D rationale
Putting and locking the side rails in place is important for safety but does not directly address the airway management needs of a client with severe obstructive sleep apnea (OSA).
Correct Answer is ["D","E"]
Explanation
Choice A rationale
Asking the healthcare provider for a mild sedative for bedtime may not be the best first-line approach for improving sleep. Sedatives can have side effects and may lead to dependency. Non-pharmacological interventions are generally preferred for managing sleep disturbances in older adults.
Choice B rationale
Taking an afternoon nap to make up for missed sleep can disrupt the sleep-wake cycle and make it harder to fall asleep at night. It is generally recommended to avoid napping during the day to improve nighttime sleep quality.
Choice C rationale
Drinking a mixture of warm water, whiskey, and honey at bedtime is not a recommended practice for improving sleep. Alcohol can disrupt sleep patterns and lead to poor sleep quality. It is better to avoid alcohol before bedtime.
Choice D rationale
Establishing a regular time for going to bed and getting up helps regulate the body’s internal clock and improve sleep quality. Consistency in sleep schedules is a key factor in promoting healthy sleep habits.
Choice E rationale
Avoiding caffeinated beverages late in the day is important for improving sleep. Caffeine is a stimulant that can interfere with the ability to fall asleep and stay asleep.