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

Answer and Explanation

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.

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Correct Answer is C

Explanation

The correct answer is C. Memory loss that disrupts activities of daily living (ADLs) is a common manifestation of dementia, which is a progressive decline in cognitive function. Pressured speech, catatonia, and illusions are more likely to be seen in clients who have psychotic disorders, such as schizophrenia or bipolar disorder.

A. Last set of the client's vital signs B. Location of the identification tag on the client's body C. Copy of the client's advance directives D. Cause of the client's death

Correct Answer is B

Explanation

Answer: B. Location of the identification tag on the client's body

Rationale: The nurse should document the location of the identification tag on the client's body to ensure proper identification and prevent errors or mix-ups during transport or autopsy. The last set of vital signs, the copy of advance directives, and the cause of death are not part of the postmortem documentation but rather part of the medical record or death certificate.

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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

A nurse is caring for a client who has dementia. Which of the following findings should the nurse expect?

Correct Answer is C

Explanation

A nurse is completing postmortem documentation for a client. Which of the following information should the nurse include in the documentation?

Correct Answer is B

Explanation

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