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Questions 164

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Question 1 of 5

Which measures will help prevent falls in the elderly clients of a long-term care facility? Select all that apply.

Correct Answer: A,B,C,E

Rationale: Exercise, lighting, handrails, and rounds reduce fall risk. Smooth-soled shoes increase slipping risk.

Question 2 of 5

A client with a recent spinal cord injury is experiencing dysreflexia and is noted to have a BP of $240 / 110$. The nurse's initial response should be to:

Correct Answer: B

Rationale: Elevating the head to a 45° angle helps reduce blood pressure in autonomic dysreflexia by promoting venous return and reducing intracranial pressure.

Question 3 of 5

The nurse is caring for a 75 year old client in congestive heart failure. Which finding suggests that digitalis levels should be reviewed?

Correct Answer: A

Rationale: Extreme fatigue. Extreme fatigue and weakness are common, early signs of digitalis toxicity, which would be confirmed by a high blood serum level of digitalis.

Question 4 of 5

Which statement by the client with chronic obstructive lung disease indicates an understanding of the major reason for the use of occasional pursed-lip breathing

Correct Answer: D

Rationale: Clients with chronic obstructive pulmonary disease have difficulty exhaling fully as a result of weak alveolar walls. Alveolar collapse can be avoided with the use of pursed-lip breathing.

Question 5 of 5

The nurse has attended a staff education program about interdisciplinary communication. The nurse should recognize that the most important outcome of effective interdisciplinary communication is

Correct Answer: C

Rationale: Effective interdisciplinary communication primarily reduces medical errors by ensuring accurate information sharing.

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