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."
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["C","D","E","F"]
Explanation
A. Stroke under the chin in a downward motion.
Explanation: Stroking under the chin in a downward motion is not considered a standard technique for managing dysphagia. It's important to focus on strategies that promote safe swallowing and prevent aspiration.
B. Keep pulse oximeter ready at all times.
Explanation: While monitoring oxygen saturation is important in certain situations, having a pulse oximeter ready at all times may not be a routine instruction for feeding a client with dysphagia. Monitoring for signs of distress and ensuring a safe feeding environment are key aspects of care.
C. Avoid rushing the client or force feeding her.
Explanation: Rushing or force-feeding a client with dysphagia can increase the risk of aspiration. It's important to allow the client to eat at their own pace and take adequate time to chew and swallow safely.
D. If facial weakness is present, place food on the impaired side of the mouth.
Explanation: Placing food on the impaired side of the mouth can help compensate for facial weakness and promote more effective chewing and swallowing.
E. Alternate solid and liquid boluses.
Explanation: Alternating solid and liquid boluses can help with the overall coordination of the swallowing process. It can also facilitate the movement of food and liquids through the digestive tract.
F. Have the client sit at 90 degrees during all of oral intake.
Explanation: Ensuring that the client sits at a 90-degree angle during oral intake helps promote an upright position that aids in swallowing and reduces the risk of aspiration.
Correct Answer is C
Explanation
A. Semiprivate room.
Explanation: Medicare can cover the cost of a semiprivate room during a qualifying hospital stay or skilled nursing facility stay.
B. Hospice care.
Explanation: Medicare provides coverage for hospice care for individuals with a terminal illness and a life expectancy of six months or less.
C. Custodial care.
Explanation: Custodial care, which involves assistance with activities of daily living (ADLs) such as bathing, dressing, and feeding, is generally not covered by Medicare. Medicare primarily covers medically necessary and skilled care, such as hospital stays, certain nursing home stays, hospice care, and some home health care services. Custodial care, which focuses on assistance with routine personal care, is considered non-medical and is typically not covered by Medicare.
D. Skilled care.
Explanation: Medicare covers skilled care, including services provided by healthcare professionals such as nurses and therapists, when deemed medically necessary. Skilled care is typically required to improve or maintain a person's condition.
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