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. During an initial visit, a home health nurse is assessing a client who has cultural beliefs different from their own. Which of the following questions should the nurse ask to determine the client's beliefs about environmental control?

Correct answer: C

Rationale: The correct question to ask in this scenario is: 'What do you think you can do to affect your health status?' This question directly addresses the client's beliefs about their ability to control their health and reflects their beliefs about environmental control. Choices A, B, and D do not directly relate to assessing the client's beliefs about environmental control. Choice A focuses on time orientation, choice B pertains to family decision-making dynamics, and choice D is related to family medical history, which are not directly relevant to understanding the client's beliefs about environmental control.

3. A healthcare provider orders a medication dose three times higher than usual. What is the nurse's first step?

Correct answer: B

Rationale: The correct answer is B: Verify the dosage with the prescribing provider. When faced with an unusual medication dose, the nurse's initial action should be to confirm the order with the healthcare provider who prescribed it. This step is crucial to prevent medication errors and ensure patient safety. Choices A, C, and D are incorrect because administering the medication without clarification, administering a lower dose without approval, or holding the medication without consulting the provider can all pose risks to the patient's well-being.

4. A client with neuropathic pain has a new prescription for amitriptyline once per day. What should the nurse include in the teaching?

Correct answer: B

Rationale: The correct answer is B: 'Increase fluids while on this medication.' Amitriptyline can cause side effects like dry mouth and urinary retention. Increasing fluids can help alleviate these side effects. Choices A, C, and D are incorrect. Taking the medication with meals or only at night is not specifically related to managing the side effects of amitriptyline. Reporting yellowing of the skin is important but not directly related to the side effects of this medication.

5. 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.

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