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
Raises all four side-rails on the client's bed
Locks the wheels on the client's bed
Clears furniture from the path leading to the bathroom
The Correct Answer is B
The correct answer is B. Raising all four side-rails on the client's bed is considered a restraint and can increase the risk of injury if the client tries to climb over them. The nurse should intervene and instruct the AP to lower one or two side-rails and use other fall prevention measures, such as bed alarms, nonskid footwear, and frequent checks.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
B. “I should discuss this document with my family after I sign it.”It is important for clients to discuss their advance directives with their family members to ensure that their wishes are understood and respected. This helps prevent confusion and ensures that family members are aware of the client’s preferences for end-of-life care.
Incorrect Options:
A. “I am not allowed to change my mind once I sign this document.”Clients can change or revoke their advance directives at any time as long as they are competent to do so.
C. “My partner needs to be present when I sign this document.”While it is a good idea to have a witness, it is not necessary for the partner to be present. The requirements for witnesses vary by jurisdiction.
D. “An attorney will need to notarize this document for it to be valid.”Not all advance directives require notarization. The requirements vary by state or country, and some may only require witnesses.
Correct Answer is B
Explanation
The correct answer is B.
"I will use abdominal breathing at the first sign of a panic attack." The rationale is that abdominal breathing helps calm the sympathetic nervous system, which is responsible for the fight-or-flight response that triggers panic attacks. Abdominal breathing also increases oxygen intake and reduces hyperventilation, which can worsen panic symptoms.
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