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
Explanation
A. Hospice care.
Explanation: Both Medicare Part A and Part B cover hospice care, and hospice care is not a fundamental difference between the two parts.
B. Home care services.
Explanation: Both Medicare Part A and Part B cover certain home care services. While the specific services covered may vary, home care services are not a fundamental difference between the two parts.
C. Health care setting.
Explanation: Medicare Part A and Part B cover different aspects of healthcare and are designed for different health care settings.
Medicare Part A (Hospital Insurance): Primarily covers inpatient hospital care, skilled nursing facility care, hospice care, and some home health care services. It is generally associated with institutional settings.
Medicare Part B (Medical Insurance): Covers outpatient care, preventive services, doctor visits, and some home health care services. It is more focused on services provided in non-institutional settings.
D. Invasive procedures.
Explanation: Both Medicare Part A and Part B cover various medical services, including invasive procedures. The nature of procedures covered may differ, but it is not a fundamental difference distinguishing between Part A and Part B.
Correct Answer is ["A","B","D"]
Explanation
A. The Global Deterioration Scale
Explanation: The Global Deterioration Scale (GDS) is a tool used to assess the cognitive function and stage of cognitive decline in individuals, especially those with dementia.
B. Mini Mental State Exam (MMSE)
Explanation: The Mini Mental State Exam (MMSE) is a widely used tool to assess cognitive function and screen for cognitive impairment. It evaluates various cognitive domains, including orientation, memory, attention, and language.
C. Older American's Resources and Services (OARS)
Explanation: The Older American's Resources and Services (OARS) is not a cognitive assessment tool. It is a comprehensive assessment tool that covers various domains, including physical health, mental health, and social resources.
D. Mini-Cog
Explanation: The Mini-Cog is a brief cognitive screening tool that includes a three-item recall test for memory and a clock-drawing task. It is used to quickly assess cognitive function and detect potential cognitive impairment.
E. The Barthel Index
Explanation: The Barthel Index is not a cognitive assessment tool. It is a tool used to assess an individual's ability to perform activities of daily living (ADLs), providing information about their functional independence rather than cognitive status.
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