A nurse is supervising an assistive personnel (AP. who is caring for a client who is at risk for falls. For which of the following actions by the AP should the nurse intervene?

Assists the client to the bathroom every 2 hr

Locks the wheels on the client's bed

Raises all four side rails on the client's bed

Clears furniture from the path leading to the bathroom

Answer and Explanation

The Correct Answer is C

A. Assisting the client to the bathroom at regular intervals helps prevent falls due to toileting needs.

B. Locking the wheels on the bed prevents unwanted movement and reduces the risk of falls when the client is in bed.

C. Raising all four side rails is considered a restraint, which can increase the risk of falls or injury if the client tries to climb over them. Restraints should be avoided unless absolutely necessary and prescribed by a healthcare provider. In most cases, raising two side rails is sufficient to prevent the client from accidentally rolling out of bed while allowing them to safely exit the bed.

D. Clearing the path from obstacles and furniture reduces the risk of falls by providing a safe and unobstructed route to the bathroom.

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Correct Answer is B

Explanation

A. Incorrect. Limiting the client's social interactions would not be helpful and might further exacerbate feelings of dependence.
B. Correct. Encouraging the client to be assertive is an important aspect of promoting independence and self-advocacy. Clients with dependent personality disorder may struggle with asserting themselves, and fostering assertiveness can improve their overall well-being.
C. Incorrect. Assuming responsibility for making the client's decisions would reinforce their dependence, which is not the goal of treatment.
D. Incorrect. Maintaining a verbal, no-harm contract is typically used for clients at risk of self-harm or harm to others and is not directly related to addressing the challenges of dependent personality disorder.

A. Allow the toddler to handle the equipment. B. Completely undress the toddler. C. Thoroughly explain each procedure to the toddler. D. Start the examination with routine immunizations.

Correct Answer is A

Explanation

A. Correct. Allowing the toddler to explore and handle the equipment can help build trust and reduce anxiety during the examination.
B. Completely undressing the toddler might cause anxiety and discomfort.
C. Thorough explanations are more suitable for older children, as toddlers might not fully understand.
D. Starting with immunizations might create anxiety, and it's better to establish rapport before introducing potentially distressing procedures.

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A nurse is supervising an assistive personnel (AP. who is caring for a client who is at risk for falls. For which of the following actions by the AP should the nurse intervene?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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