A nurse is caring for a client who is on fall precautions. Which of the following actions should the nurse take?

Silence the bed alarm when visitors are at the client's bedside.

Establish an elimination schedule for the client.

Raise all four bed rails on the client's bed.

Allow the client to walk unassisted near the nursing station

Answer and Explanation

The Correct Answer is B

A. Silence the bed alarm when visitors are at the client's bedside. Bed alarms are a critical safety device for clients on fall precautions and should never be silenced when the client is in bed, regardless of visitors. Alarms alert staff if the client attempts to get up unsafely.
B. Establish an elimination schedule for the client. A regular toileting schedule helps reduce the risk of falls by preventing unassisted attempts to get out of bed to use the bathroom. This proactive approach supports both safety and comfort.
C. Raise all four bed rails on the client's bed. Raising all four rails is considered a form of restraint and can actually increase the risk of injury if the client attempts to climb over them. Two rails up is generally acceptable for support and safety.
D. Allow the client to walk unassisted near the nursing station. Clients on fall precautions should always be supervised or assisted during ambulation to prevent accidents, even when close to staff. Being near the nursing station does not eliminate the risk.

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Correct Answer is B

Explanation

A. Delayed. Delayed grief is characterized by the postponement or suppression of grieving responses, often surfacing long after the loss has occurred. It does not apply here, as the family member is expressing active emotional struggle before the loss.
B. Anticipatory. Anticipatory grief occurs before an actual loss, such as when a loved one is dying from a terminal illness. The family member is beginning to grieve the impending death and the emotional impact of the future loss, which fits this type of grief.
C. Disenfranchised. Disenfranchised grief refers to grief that is not openly acknowledged or socially supported, such as the death of an ex-partner or a pet. In this scenario, the grief is acknowledged and supported, so this does not apply.
D. Exaggerated. Exaggerated grief involves intense symptoms that interfere with daily functioning, such as severe depression, phobias, or suicidal thoughts. The family member is expressing difficulty, but not at a level that indicates dysfunction.

A. Use short sentences when communicating with the client. B. Tell the client to sit alone in a private place and reflect on the situation. C. Encourage the client to talk about his feelings. D. Have the client journal about what is happening to him.

Correct Answer is A

Explanation

A. Use short sentences when communicating with the client. In a panic level of anxiety, the client has impaired concentration, perception, and understanding. Using short, simple sentences helps the client process communication more easily and reduces cognitive overload.
B. Tell the client to sit alone in a private place and reflect on the situation. A client in a panic state may feel unsafe or overwhelmed when left alone. Supervision and a calm presence are essential until the anxiety level decreases.
C. Encourage the client to talk about his feelings. Clients in a panic state are often unable to verbalize or reflect on their emotions clearly. Talking about feelings is more appropriate once the anxiety has decreased to a moderate level.
D. Have the client journal about what is happening to him. Journaling requires organized thought and concentration, which is not possible during a panic-level anxiety episode. It may be useful later, during a lower level of anxiety.

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