Questions → Task Question

Rationale
Answer A: Incorrect - although bladder training exercises should be encouraged, this
does not provide safety for the client at night
Answer B: Incorrect - assistance with toileting is necessary, but every 4 hours may not
be the correct time frame
Answer C: Incorrect - fluids may be decreased during the evening hours, but should not
be avoided completely
Answer D: Correct - positioning a commode near the bedside requires less energy than
walking to the bathroom and provides more safety for the client
Question
The nurse cares for the client diagnosed with arthritis requiring a walker to safely
ambulate. The client reveals to the nurse that she gets up several times during the night
to void. Which action by the nurse is most appropriate?
A.
Implement bladder training exercises.
B.
Provide assistance with toileting every 4 hours.
C.
Instruct the client to eliminate fluids after 5 p.m.
RIGHT
D.
Position a bedside commode near the bed.
Questions → Task Question
Rationale
Answer A: Correct - prevents shadows and potential misinterpretation of stimuli
Answer B: Incorrect - when talking with an older client it is better to use a lower pitch of
voice to overcome the common loss of hearing higher pitched sounds that occurs with
aging; does not help keep client safe when ambulating
Answer C: Incorrect - if client is unsafe ambulating, use a safety belt
Answer D: Incorrect - maintaining a clear walkway is important; furniture is not the only
physical hazard that can contribute to falls
Question
The nurse plans care for a client diagnosed with arthritis. Which nursing intervention
enhances an older adult's sensory perception and helps prevent injury when the client
walks from the bed to the bathroom?

RIGHT
A.
The nurse ensures adequate lighting.
B.
The nurse raises the pitch of the voice when speaking to the
client.
C.
The nurse holds onto the client's arm.
D.
The nurse removes environmental hazards.
O.S. has a significant risk for falls. The nurse should evaluate the client's baseline
mobility and assess her progress with weekly physical therapy. The nurse should
encourage the client to engage in activities of her liking at the facility and not take away
from her independence. However, safety is of concern and the nurse should encourage
the client to wear her glasses and hearing aid when ambulating and educate her on the
importance of adequate lighting and other safety measures (hand rails, no floor rugs,
etc.) within her apartment. The client's close monitoring of her diet and her limited fluid
intake warrant diagnoses of Imbalanced Nutrition, Less Than Body Requirements and
Risk for Fluid Deficit. The nurse should intervene by determining the client's food and
fluid preferences and collaborating with dietary to ensure that there are appealing items
for O.S. to choose from. The nurse should also educate the client on the importance of
good fluid intake (6-8 glasses/day) and a healthy diet (utilize the food plate). O.S. is very
good at monitoring her own intake and should be encouraged to record her oral intake
on a weekly basis to make sure she is getting the calories, nutrients, and fluids that she
needs. The nurse should also monitor the client's weight weekly to assess for any
significant weight loss or gain. The client's social functioning and interaction is a
concern, following the loss of her lifelong companion (her sister) must be addressed
after priority concerns are identified. She should be encouraged to express her feelings
and talk with facility resources (clergy, social workers, etc.) and others who have lost
loved ones. The client's interests should be assessed and the nurse should promote her
participation in activities with other facility residents.
Client Content V. 3

Care Plans Scoring Explanation:

Your Selecting Interventions score reflects the number of correct nursing interventions
you selected. It is expressed both in raw numbers and as a percentage.
Your Questions score reflects the number of questions that you got correct, compared
to the total number of questions in this section. It is expressed both in raw numbers and
as a percentage.
Your Module Total reflects your total score for Selecting Interventions and Questions. It
is expressed both in raw numbers and as a percentage.
The Selection Errors tab displays a list of incorrect interventions that you included in
your plan of care. Please take note of these errors, especially those that could
result in harm to the client.
Omitted Selections are criteria identified by the case author that you omitted. Some
items are marked as Essential to planning care for the client. Omitting one or more
essential item is considered a flaw in the plan of care.
Falls, Risk for

RIGHT
Instruct client to wear hearing aids and glasses whenever ambulating

RIGHT
Reinforce safety measures in apartment (hand rails in bathroom, emergency call light in
bedroom)

RIGHT
Educate client on necessity to have adequate lighting

RIGHT
Assist client to identify environmental factors that increase risk for falling (poor lighting,
throw rugs)
Social Interaction, Impaired

RIGHT
Provide opportunity for client to express feelings of loss over sister

RIGHT
Assess client interests

RIGHT
Encourage client to become involved in activities offered by Assisted Living Facility

RIGHT
Help client identify support resources (family, clergy, other residents who have lost
family members)
Mobility, Impaired: Physical

RIGHT
Instruct client to take pain medication one hour prior to activity

RIGHT
Assess baseline range of motion and distance client is able to walk

RIGHT
Monitor client's progress with physical therapy weekly

RIGHT
Encourage client to participate in activities provided at residence

RIGHT
Consult with physical therapy to develop plan for progressive activity
Fluid Volume, Risk for Deficient

RIGHT
Determine client fluid preferences and collaborate with dining room and family to
provide those fluids

RIGHT
Weigh client daily for the next 4-5 days

RIGHT
Teach client importance of maintaining adequate fluid intake - prevent dehydration,
prevent urinary tract infections

RIGHT
Teach client method to monitor intake - number of 6 or 8 oz. glasses per day
Nutrition, Imbalanced: Less Than Body Requirements

RIGHT
Teach client food the food plate (MyPlate) and appropriate number and size of servings
per category

RIGHT
Assess current dietary intake by having client record everything eaten in a one-week
period

RIGHT
Weigh client once per week

RIGHT
Assist client to plan healthy lunches and snacks. Breakfast and dinner provided by
assisted care facility