A nurse at a long-term facility is planning a fall prevention program for the residents. Which of the following interventions should the nurse include?
Institute rounds every 2 hr. during the day to offer toileting.
Keep four side rails up on the beds at night
Apply vest restraints on the residents who are confused
Accompany residents older than 85 years of age during ambulation
The Correct Answer is A
a. Instituting rounds every 2 hours during the day to offer toileting can help prevent falls by addressing residents' toileting needs and reducing the risk of falls associated with attempting to ambulate to the bathroom independently.
b. Keeping four side rails up on the beds at night may increase the risk of entrapment and should be avoided as a fall prevention strategy.
c. Applying restraints, such as vest restraints, is not recommended as a fall prevention measure and may increase agitation and risk of injury.
d. While providing assistance during ambulation is important, it is not necessary to accompany all residents older than 85 years of age. Ambulation assistance should be provided based on individual assessment of mobility and fall risk.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
a. Anorexia nervosa is a complex psychiatric disorder, and the client would benefit from the expertise of a mental health counselor to address underlying psychological issues.
b. Nutritional therapy is crucial in the treatment of anorexia nervosa to address malnutrition and establish healthy eating habits.
c. While physical therapy may be necessary in some cases, it is not typically the primary focus of care for clients with anorexia nervosa.
d. A case manager may assist with coordinating care, but they may not have the specialized knowledge required to address the specific needs of a client with anorexia nervosa.
e. An occupational therapist focuses on helping clients perform activities of daily living and may not be directly involved in the treatment of anorexia nervosa unless there are specific functional limitations that need addressing.
Correct Answer is D
Explanation
a. A client at 37 weeks gestation with an L/S ratio of 2:1 is likely nearing term and may not require an interdisciplinary care conference solely based on this result.
b. A negative Coombs's titer at 28 weeks gestation does not typically warrant an interdisciplinary care conference.
c. A client at 39 weeks gestation with a negative contraction stress test may not require an interdisciplinary care conference unless there are other concerning factors.
d. A biophysical profile of 6 at 35 weeks gestation suggests potential fetal compromise and warrants further evaluation and discussion among interdisciplinary team members in a care conference.
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