A nurse at a long-term care facility is planning a fall prevention program for the residents. Which of the following interventions should the nurse include?
Keep the four side rails up on beds at night.
Institute rounds every 2 hr during the day to offer toileting
Accompany residents older than 85 years of age during ambulation
Apply vest restraints on residents who are confused.
Apply vest restraints on residents who are confused.
The Correct Answer is B
A. Keeping all four side rails up on beds can increase the risk of entrapment or injury and isn't recommended as a fall prevention strategy.
B. Instituting regular rounds during the day to offer toileting helps prevent falls related to residents attempting to get to the bathroom independently.
C. Accompanying older residents during ambulation is helpful but might not be feasible at all times and for all residents.
D. Using vest restraints can lead to physical and psychological complications and is not recommended due to ethical and safety concerns.
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Related Questions
Correct Answer is C
Explanation
A. Contacting the provider may be part of the process, but it does not directly address the conflict between the family members' wishes and the health care surrogate's legal authority.
B. While the ethics committee can be a valuable resource in resolving disputes, it is not the first step in this situation, as the health care surrogate has the legal right to make decisions on behalf of the unconscious client.
C. The health care surrogate is legally designated to make health care decisions for the client when they are unable to do so themselves. This includes decisions about life-sustaining treatments such as a feeding tube.
D. Reviewing the client's advance directives is important, but it does not supersede the authority of the health care surrogate unless the directives explicitly limit the surrogate's decision-making power.
Correct Answer is B
Explanation
A. Keeping all four side rails up on beds can increase the risk of entrapment or injury and isn't recommended as a fall prevention strategy.
B. Instituting regular rounds during the day to offer toileting helps prevent falls related to residents attempting to get to the bathroom independently.
C. Accompanying older residents during ambulation is helpful but might not be feasible at all times and for all residents.
D. Using vest restraints can lead to physical and psychological complications and is not recommended due to ethical and safety concerns.
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