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 D
Explanation
A. While involving the family might be beneficial for education, it's not directly related to assessing the client's needs for turning.
B. Assessing the client's pain level is important, but it's only one aspect of comprehensive care when delegating turning to the AP.
C. Checking the AP's availability for other tasks after turning the client is important but not the primary assessment before delegation.
D. Before delegating care, the nurse should assess and collect data about the client's specific needs related to turning due to the client's condition. Understanding the client's condition and requirements for turning is crucial for effective delegation.
Correct Answer is D
Explanation
A. A generalized rash over the trunk might indicate various conditions but might not be an immediate concern in the context of meningitis.
B. An increased temperature is an expected finding in meningitis and should be
monitored but might not necessitate immediate reporting unless exceptionally high or coupled with other concerning symptoms.
C. Photophobia, or sensitivity to light, is a common symptom in meningitis but alone might not necessitate immediate reporting if the client's other symptoms are stable.
D. Decreased level of consciousness can indicate neurological deterioration and requires immediate attention as it could signal worsening of the client's condition.
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