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 B
Explanation
A. It's not mandatory for a health care proxy to be a member of the client's family; the most important aspect is appointing someone the client trusts to make decisions on their behalf.
B. A health care proxy is someone designated by the client to make medical decisions when the client is unable to do so, based on the client's preferences and wishes.
C. While it's advisable to have an advance directive in place before procedures or when facing serious illnesses, the timing of appointing a health care proxy should not be confined to only these situations.
D. It is not necessary for an attorney to approve the appointment of a health care proxy; the client can designate someone they trust without legal counsel's approval.
Correct Answer is B
Explanation
A. Collaborative, user-edited websites might contain varying levels of accuracy and reliability regarding medical information, making them less suitable for obtaining specific prevalence data.
B. An evidence-based nursing journal is a reliable source of information that often includes statistical data, prevalence rates, and updated research on various medical conditions, including Tay-Sachs disease.
C. The facility's case manager might have general information but may not provide specific prevalence rates for Tay-Sachs disease.
D. While the client's health care provider might have knowledge about Tay-Sachs disease, their primary focus during a clinical encounter might be the client's immediate care needs rather than providing statistics on disease prevalence.
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