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54. A nurse at an acute care facility is teaching a client about fall risk prevention strategies for use during their stay at the facility. Which of the Following statements by the client indicates an understanding of the teaching? 1. will wear a yellow wristband so everyone knows I am at risk of falling.” 2. “I should keep the overhead lights on at all times while I am here.” 3. “will have to wear a restraint around my waist when I am sitting up in a chair.” 4. “I should store my personal items all together on the shelf in my bathroom.” 44. Anurse is assessing a 24-month-old toddler at a well-child checkup. Which of the following findings indicates to the nurse that the toddler has a developmental delay? 1. Falls when throwing a ball overhand 2 Runs with a wide stance 3. Goes up stairs with two feet on each step 4. Refers to sell by name 38. A nurse is planning care for a client who is undergoing brachytherapy with a low-dose radiation implant for treatment of prostate cancer. Which of the following interventions should the nurse include in the client’s plan of care? 1. Instruct visitors to stay 1 m (3.3 feet) away from the client 2. Attach a dosimeter to the client’s gown. 3. Strain the client’s urine. 4. Limit each of the client’s visitors to 2 he per day, 42. A school nurse is using the Weber’s test to check a child’s hearing acuity. Which of the following actions should the nurse take? 1. Measure the amount of time the child can hear the sound. 2. Obtain a tympanogram reading prior to initiating the test. 3. Hold a vibrating tuning fork 1 to 2 cm (0.4 to 0.8 in) from the child’s cars. 4. Place a vibrating tuning fork on the top of the child’s head. X ? ? ? ? 30 888 ** 12 A ) the %23 3 % 5 & 7 6 8 9 – o E R Y P T U 0 D F H к ” 니
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