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 A

Explanation

A. Constipation.

Explanation: Constipation is a common side effect of opioid medications like morphine. Older adults, particularly those on bed rest or with reduced mobility, are already at an increased risk of constipation. Morphine further contributes to this risk by slowing down bowel motility. Preventive measures such as promoting adequate hydration, encouraging fiber intake, and considering stool softeners can help prevent constipation in this scenario.

B. Poor solid food intake.

Explanation: While monitoring and addressing poor solid food intake are important for overall nutritional status, it may not be the immediate priority related to morphine use and postoperative care.

C. Poor liquid intake.

Explanation: Ensuring adequate fluid intake is important for overall hydration, but constipation is a more specific and immediate concern associated with opioid use.

D. Diarrhea.

Explanation: Diarrhea is not a common side effect of morphine and is less likely to be the priority for preventive care in this situation. Constipation is a more anticipated concern when opioids are prescribed.

A. Has a history of alcohol abuse B. Bathes three to four times a week C. Has a history of diabetes mellitus D. Becomes diaphoretic on warm days E. is prescribed antidepressant F. Has a history of a cerebrovascular accident CVA

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

Explanation

A. Has a history of alcohol abuse
Explanation: Alcohol can contribute to hypothermia as it causes vasodilation, leading to heat loss. It can impair the body's ability to regulate temperature.

B. Bathes three to four times a week
Explanation: While personal hygiene is important, the frequency of bathing alone may not be a direct risk factor for hypothermia. The overall environmental temperature and the individual's ability to regulate their body temperature are more critical considerations.

C. Has a history of diabetes mellitus
Explanation: Diabetes mellitus can increase the risk of hypothermia as it may affect circulation and peripheral nerve function. Impaired sensation and reduced blood flow can contribute to difficulty in maintaining body temperature.

D. Becomes diaphoretic on warm days
Explanation: Excessive sweating (diaphoresis) can contribute to the risk of hypothermia, as it leads to moisture loss from the skin, making it more challenging for the body to maintain a stable temperature.

E. Is prescribed antidepressant
Explanation: While certain medications, including some antidepressants, can affect thermoregulation, the prescription of an antidepressant alone does not necessarily indicate an increased risk of hypothermia. It is essential to consider the specific medication and its potential side effects.

F. Has a history of a cerebrovascular accident (CVA)
Explanation: Individuals with a history of a cerebrovascular accident may have impaired thermoregulation due to damage to the central nervous system. This can increase susceptibility to temperature extremes.

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Naxlex Comprehensive Predictor Exams

An older adult who is on bed rest after surgery is prescribed morphine for pain. Which of the following is the nurse's priority for preventive care?

Correct Answer is A

Explanation

The nurse plans care to prevent a dangerous thermal environment for an older adult client who lives in a northern climate of the United States. Which client assessment data does the nurse recognize that can contribute to the risk of hypothermia? (Select all that apply.)

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

Explanation

The nurse should encourage which of the following exercise(s) to assist with balance for a client who is at high risk for falls? (Select all that apply.

Which of the following is a true statement about elimination in older adults?

A client care assistant has been assigned to feed your female client with dysphagia. Which of the following instructions would you give the assistant? (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?

Which one of the following is connected with the nursing home reform mandated by a 1987 law?

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.)

The health care provider has not ordered the use of a restraint for an alert patient at high risk for falling. The nurse should implement which side rail use?

The nurse is trying to improve the nutritional status of residents in the nursing home. Which recommendations should the nurse implement?