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. Tell her to use an assistive device until her balance improves.

Explanation: While using an assistive device may provide support, it is not a comprehensive solution for improving balance. Addressing balance issues usually involves a combination of exercises and interventions tailored to the individual's needs.

B. Provide information on group exercises for balance training.

Explanation: Group exercises specifically designed for balance training can be beneficial for an older adult who is recovering from balance issues and falls. These programs often include exercises targeting stability, coordination, and strength, and they are led by professionals who can provide guidance and supervision. Group exercises also offer a social component, promoting motivation and adherence to the program.

C. Instruct her to enroll in a general exercise program for 8 weeks.

Explanation: A general exercise program may not specifically focus on balance training. Tailoring the program to address balance issues is more appropriate for the client's needs.

D. Help her to learn how to exercise the core group of muscles.

Explanation: While exercising the core muscles can contribute to overall stability, a broader approach that includes balance-specific exercises is preferable for someone recovering from balance issues and falls. Balance training often involves exercises that target various muscle groups involved in maintaining stability.

A. Age-related motor deficiencies that result in self-neglect B. Age-related neurosensory changes that diminish awareness of temperature changes C. Delirium-related to an acute illness that is affecting body heat production D. Cognitive changes that diminish the individual's awareness of temperature changes

Correct Answer is B

Explanation

A. Age-related motor deficiencies that result in self-neglect.

Explanation: While age-related motor deficiencies could potentially impact a person's ability to dress appropriately, the specific scenario described (wearing a sweater despite high temperatures) is more indicative of sensory awareness issues rather than motor deficiencies.

B. Age-related neurosensory changes that diminish awareness of temperature changes.

Explanation: As individuals age, there can be neurosensory changes that affect their ability to perceive temperature accurately. This can result in older adults being less aware of changes in temperature, leading to behaviors such as dressing inappropriately for the weather. In this scenario, the client wearing a sweater despite the high temperature outside may be attributed to diminished awareness of the actual environmental temperature.

C. Delirium related to an acute illness that is affecting body heat production.

Explanation: Delirium may indeed affect a person's cognitive and functional abilities, but the scenario does not provide evidence of delirium or an acute illness. The focus is on the client's behavior related to dressing inappropriately for the weather, which is more suggestive of sensory awareness issues.

D. Cognitive changes that diminish the individual's awareness of temperature changes.

Explanation: This option is similar to the correct answer (Option B). Cognitive changes, particularly in awareness, can contribute to inappropriate dressing for the weather in older adults. The primary distinction here is that the term "neurosensory changes" in Option B specifically highlights alterations in sensory perception.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse wants to suggest exercise program options for an older client who is recovering losing her balance and falling. Which nursing intervention is suitable for this older adult?

Correct Answer is B

Explanation

A 79-year-old client resides independently in the community. The visiting home health nurse finds that despite it being 90°F outside, the windows are closed and the client is wearing a sweater. The nurse initially recognizes that this behavior may be related to what?

Correct Answer is B

Explanation

A nurse counseling an 85-year-old person regarding modifying driving habits would include

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.)

Which option is part of a program that addresses bowel incontinence in an older adult client?

Which of the following statements is true about conservators?

The overall temperature in the gerontological unit is 62°F during the evening shift. In documenting this concern to the administration, which factor is the most important for the health and well-being of older adults?

The nurse assesses the quality of which of the following patient characteristics when applying the Get-Up-and-Go test from the Hendrich II Fall Risk Model?

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?