A nurse is admitting a client who is at risk for falls to a medical-surgical unit. Which of the following actions should the nurse take?
Elevate full-length side rails on both sides of the client's bed.
Place the bedside table 0.9 m (3 feet) away from the bed.
Provide the client with a night light.
Keep the client's room temperature at 18° C (64.4" F).
The Correct Answer is C
A. Elevating full-length side rails on both sides of the client's bed is not recommended, as it can increase the risk of injury if the client tries to climb over them or gets trapped between them.
B. Placing the bedside table 0.9 m away is unrelated to fall prevention.
C. A night light can help the client see better in the dark and avoid tripping or falling over objects.
D. Maintaining the room temperature is important for comfort but doesn't directly prevent falls.
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Related Questions
Correct Answer is A
Explanation
- Rationale for A: Rolling the client as one unit helps maintain spinal alignment and prevents further injury. It ensures that no additional strain is placed on the injured area, which could exacerbate pain or cause further damage. This method distributes the client's weight evenly and avoids twisting movements that could be harmful.
- Rationale for B: While flexing the client's knees may be part of the process to prepare for repositioning, it is not the most critical action to take. Flexing the knees alone does not ensure the safety of the client's lower back and could potentially lead to discomfort or injury if not done in conjunction with other measures.
- Rationale for C: Placing the client's arms at their sides is not advisable as it does not provide any support or stability during the repositioning process. Arms should be positioned in a way that they do not bear weight or interfere with the movement, ensuring the client's comfort and safety.
- Rationale for D: While placing the client on the side of the bed nearest the direction they will be turned may seem practical, it is not the primary action to ensure the client's safety. This position does not address the need for maintaining proper spinal alignment or the smooth, controlled movement required to protect the lower back injury.
Correct Answer is A
Explanation
A. Speech-language pathologists specialize in assessing and managing swallowing difficulties (dysphagia) after a stroke.
B. Social workers primarily address psychosocial aspects and may not directly manage swallowing difficulties.
C. Physical therapists focus more on mobility and physical rehabilitation.
D. Occupational therapists help with daily living activities but might not specialize in dysphagia management.
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