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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["B","C"]
Explanation
A. Not indicated and could lead to complications.
B. The client reports abdominal cramping and a small, hard, painful bowel movement. A sit bath can help provide relief and comfort to the perineal area, which can be beneficial after experiencing bowel discomfort.
C. The client reports pain and has had a small, hard, painful bowel movement. Encouraging oral fluid intake helps prevent dehydration and can soften the stool, making it easier to pass and reducing the risk of constipation.
D. Not necessary or appropriate without further assessment.
E. Not necessary and may not provide any additional benefit in this context.
Correct Answer is ["B","D"]
Explanation
The correct answer is Choices B and D.
Choice A rationale: Using confrontation to manage a client’s behavior is not recommended, especially for clients with Alzheimer’s disease. Confrontation can lead to increased agitation, confusion, and distress in these clients. It’s important to approach clients with Alzheimer’s disease in a calm, reassuring manner and to validate their feelings and experiences.
Choice B rationale: Limiting the number of choices for the client is a beneficial strategy when caring for clients with Alzheimer’s disease. Too many choices can overwhelm these clients and lead to increased confusion and frustration. By simplifying decisions, caregivers can help to reduce the client’s stress and improve their ability to function.
Choice C rationale: While it’s important to keep clients with Alzheimer’s disease engaged and stimulated, providing a stimulating environment can be counterproductive. Too much stimulation can overwhelm these clients and lead to increased confusion and agitation. It’s more beneficial to provide a calm, quiet, and familiar environment for these clients.
Choice D rationale: Using written signs to assist the client with locating the bathroom can be very helpful for clients with Alzheimer’s disease. As the disease progresses, these clients often struggle with memory loss and disorientation. Clear, simple signs can help them navigate their environment and maintain a level of independence.
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