Question

N350 clinical week 1 NCLEX questions 4. Mary has completed the orientation program and is now working on the client care unit with a nurse mentor, Libby. Together they review their assigned clients. The client in room 1104 has just been admitted. Which factors in this client's admission assessment and earlier history indicate that she is at risk for falls? Select all that apply. a. Her age of 87 b. Disorientation c. History of falls d. Taking a "fluid pill" daily e. History of hypothyroidism f. Use of an assistive device (walker) At 3 a.m., a nurse is making her rounds. She finds a client with Alzheimer's disease climbing over the side rails of his bed. The nurse rushes to the client and assists him back into bed. Which action should the nurse take first to ensure client safety? 5. a. Asking an unlicensed assistive personnel (UAP) to stay with the client b. Calling the client's health care provider for a prescription for a safety device c. Checking for a prescription for a sedative and administering the sedative d. Asking another nurse to obtain a safety device from the supply closet so that the client may be restrained

Answer 1

4a.With advancing age the risk for falls increase.

c. Previous history of falls is a warning bell for future falls.

e metabolic causes such as history of hypothyroidism is also a reason for fall.

5d Sedatives will have only a short term effect and is not an immediate response.

Unlicensed assistive personnel will have less knowledge about the patients condition.

So it is better to call another nurse for support and ask her to obtain safety device from the closet.