A nurse admitting and orienting an older adult to the hospital unit discusses fall prevention and demonstrates the use of the call bell to the patient. The patient's daughter asks: "Why don't you just put up all the side rails to prevent my mother from getting out of bed by herself and falling. That should work, right?" What is the nurse's best response?

"Side rails do not decrease falls, but they do decrease fall related injuries."

"There is no evidence that side rail use decreases falls, and in fact, there is a greater risk of injury."

"Side rails are only effective when used with patients who have dementia"

Side rails have only proven to be effective in decreasing falls in patients who have already fallen."

Answer and Explanation

The Correct Answer is B

A. "Side rails do not decrease falls, but they do decrease fall-related injuries."

Explanation: While side rails may reduce the severity of injuries if a fall occurs, they are not proven to decrease the overall rate of falls. Additionally, side rails themselves can pose risks, including entrapment.

B. There is no evidence that side rail use decreases falls, and in fact, there is a greater risk of injury."

Explanation: The use of side rails as a fall prevention measure has been associated with risks and has not been shown to effectively decrease the overall rate of falls. There is evidence that side rails can contribute to injuries, including entrapment, when patients attempt to climb over or through them. The focus in fall prevention has shifted towards individualized assessments, environmental modifications, and other strategies that address the specific needs and risks of each patient.

C. "Side rails are only effective when used with patients who have dementia."

Explanation: The effectiveness of side rails is not limited to patients with dementia. However, the use of side rails as a general fall prevention strategy has been questioned, and their use should be carefully considered based on individual assessments and risks.

D. "Side rails have only proven to be effective in decreasing falls in patients who have already fallen."

Explanation: The use of side rails is not universally proven to be effective in decreasing falls, even in patients who have previously fallen. The decision to use side rails should be based on a thorough assessment of the individual's needs and risks, considering alternatives to promote safety.

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Correct Answer is B

Explanation

A. Encouraging the client to use a cane when ambulating.

Explanation: Encouraging the use of a cane for ambulation can provide support and stability, aiding in fall prevention.

B. Keeping the side rails up on the client's bed at night.

Explanation: Keeping side rails up on the client's bed can pose a concern as it may increase the risk of entrapment and injury. Side rails can lead to accidental entrapment, and there is a potential for the client to try to climb over them, leading to falls or injuries. The use of side rails in older adults is a safety consideration that requires careful assessment and appropriate measures to prevent harm.

C. Keeping several low wattage night lights on in the evening.

Explanation: Using low wattage night lights is a good practice to enhance visibility and prevent tripping or stumbling in low-light conditions.

D. Installing wooden railings on the stairway to the bathroom.

Explanation: Installing railings on the stairway is a proactive measure to enhance safety and stability, especially in navigating stairs, and can contribute to fall prevention.

A. Making refreshment stations readily available B. Caloric supplements with the meals C. Providing feeding assistance D. Optimal social supports

Correct Answer is ["A","B","C","D"]

Explanation

A. Making refreshment stations readily available

Explanation: Making refreshment stations readily available can encourage individuals with dementia to access snacks and beverages independently. This can help ensure a consistent intake of calories and nutrients throughout the day.

B. Caloric supplements with the meals

Explanation: Caloric supplements can provide additional nutrients and energy, especially if the client has difficulty consuming an adequate amount of food during meals. Consultation with a healthcare professional is recommended to determine the appropriate type and amount of supplements.

C. Providing feeding assistance

Explanation: Offering feeding assistance, such as help with cutting food into manageable pieces or providing cueing and encouragement during meals, can support individuals with dementia in maintaining proper nutrition.

D. Optimal social supports

Explanation: Optimal social supports, including family members, caregivers, or support groups, can play a crucial role in monitoring the nutritional status of individuals with dementia. Social interactions during meals can positively impact eating behaviors, and caregivers can provide assistance and encouragement.

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Naxlex Comprehensive Predictor Exams

Which attempt by the family to prevent an older frail adult from falling causes the home health nurse concern?

Correct Answer is B

Explanation

To prevent malnutrition in older clients with dementia, which of the following would benefit your client? (Select all that apply.)

Correct Answer is ["A","B","C","D"]

Explanation

Which recommendations for daily food intake is correct for older adults according to the MyPlate for Older Adults? (Select all that apply.)

Which of the following assessments should be included in a post fall prevention assessment of an older adult? (Select all that apply.)

A home health nurse is making a home visit to an older adult client. A nurse conducts a home safety assessment and screens the environment for potential hazards for falls. The nurse recommends that the client eliminate which of the following? (Select all that apply.)

A health care provider asks the nurse about an older adult client's durable power of attorney (POA) because consent is needed for a medically necessary invasive procedure. The client has end-stage disease, is intubated, and is on mechanical ventilation. Which steps should the nurse implement?

An older client is being discharged from the hospital to a sub-acute unit. The client says to a nurse, "I am not sure I understand the difference between a sub-acute unit and a nursing home. Can you help me understand?" The nurse considers which of the following in formulating a response:

In reviewing an older adult's insurance history, you find that he is on Medicaid. What do you know that Medicaid is used for?

The Bill of Rights for long-term residents was created to protect the rights of the residents in nursing homes. Which of the following examples protect these rights? (Select all that apply.)

A nurse is assessing an older adult's nutritional status. The nurse understands that which of the following is the most important indicator for a potential nutritional deficit?