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 D

Explanation

A. Blood urea nitrogen measures kidney function, is not related to thyroid health.
B. Arterial blood gases are used to assess oxygen and carbon dioxide levels in the blood, not related to thyroid health.
C. Prothrombin time is a test used to assess blood clotting, not related to thyroid health.
D. Correct. Monitoring thyroid stimulating hormone (TSH. levels is crucial for assessing the function of the thyroid gland and adjusting levothyroxine dosage as needed.

A. Knee joint B. Interphalangeal joint C. Ankle joint D. Shoulder joint

Correct Answer is D

Explanation

A) Incorrect. The knee joint is a hinge joint that allows primarily flexion and extension.
B) Incorrect. The interphalangeal joints are hinge joints that allow primarily flexion and extension of the fingers and toes.
C) Incorrect. The ankle joint is a hinge joint that allows primarily dorsiflexion and plantarflexion of the foot.
D) Correct. The shoulder joint is a classic example of a ball and socket joint, allowing for a wide range of motion in various directions, including flexion, extension, abduction, adduction, rotation, and circumduction.

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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

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