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

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?

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 director of nursing at a long-term care center has announced a change to computerized documentation of nursing care. A certified nursing assistant (CNA) on the team, resistant to the change, is not taking an active part in facilitating the implementation of the new procedure. Which strategy would be the best approach to dealing with the conflict?

Correct answer: A

Rationale: The best approach to dealing with resistance to change is through open communication and understanding. Meeting with the CNA and encouraging him to express his feelings regarding the change allows for a constructive dialogue where issues can be addressed, and alternative solutions can be explored. Ignoring the resistance does not help in resolving the conflict and may lead to further issues. Telling the CNA that a licensed practical nurse (LPN) will perform all computer documentation while he documents intake and output and vital signs does not address the underlying concerns of the CNA and may create more resistance. Threatening the CNA with noncompliance consequences may escalate the resistance and create a negative work environment.

3. A client expresses anxiety about having magnetic resonance imaging performed. Which of the following is an appropriate response by the nurse?

Correct answer: A

Rationale: The correct response acknowledges the client's anxiety and offers a practical solution to alleviate it, showing empathy and addressing the client's concerns. Offering a sedative to help relax during the test is a proactive approach to managing the client's anxiety. Choices B and C dismiss the client's feelings by invalidating their anxiety, which can further escalate their distress. Choice D downplays the client's feelings by implying they should not be worried, which does not effectively address the client's emotional state.

4. All of the following are causes of vaginal bleeding in late pregnancy except:

Correct answer: B

Rationale: The correct answer is B: Eclampsia. Eclampsia is a disorder of pregnancy characterized by hypertension, proteinuria, and edema. This condition can cause seizures and/or coma but does not typically present with vaginal bleeding. Choices A, C, and D are abnormal conditions that can cause bleeding, particularly in the third trimester. Placenta previa (choice A) is a condition where the placenta partially or completely covers the cervix, leading to vaginal bleeding. Abruptio placentae (choice C) is the premature separation of the placenta from the uterine wall, causing vaginal bleeding. Uterine rupture (choice D) is a serious obstetrical emergency where the uterus tears during pregnancy or childbirth, resulting in severe bleeding.

5. The LPN needs to delegate a task to the nurse aide who is new to the unit. Which of these is the best option for the nurse to choose in proceeding?

Correct answer: B

Rationale: Delegation is transferring responsibility for a task but sharing its accountability. It is the delegator's responsibility to ensure that the delegatee understands the task before it is performed and to follow up afterward to ensure it was completed correctly and safely. Option B is the best choice because it allows the nurse to observe the nurse aide performing the task without pressure, which can provide insights into the aide's abilities and understanding. This method also allows for immediate feedback and correction if needed. Choice A is incorrect because confirming understanding alone may not provide a complete picture of the aide's competence in performing the task. Choice C is incorrect as it suggests supervising only if needed, which may not provide adequate oversight for a new nurse aide. Choice D is incorrect because supervising the task being performed does not allow for an objective assessment of the aide's abilities and understanding.

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