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
Answer: B.I will get you information about some head-covering options." Explanation: This response shows empathy and respect for the client's concerns and provides information and support for coping with hair loss. The other responses are dismissive, evasive, or intrusive.
Correct Answer is A
Explanation
Choice A reason:
"Use a cane when walking to maintain your balance" is the correct statement Multiple sclerosis (MS) is a chronic autoimmune condition that affects the central nervous system, leading to various neurological symptoms. Mobility and balance issues are common among individuals with MS, and using a cane can be helpful in providing stability and support while walking. It can also reduce the risk of falls and improve the client's overall safety and confidence when ambulating.
Choice B reason:
"Plan to take a hot bath once a week to reduce stress” is not appropriate statement. Heat sensitivity is a common symptom in individuals with MS, and exposure to heat, such as hot baths or saunas, can exacerbate MS symptoms. It is generally advisable for individuals with MS to avoid excessive heat exposure as it can worsen fatigue and other neurological symptoms.
Choice C reason:
"Engage in a rigorous exercise program to maintain muscle tone" is not appropriate. While exercise is beneficial for individuals with MS, particularly in maintaining muscle strength and flexibility, it is essential to avoid a rigorous or overly strenuous exercise program. High-intensity exercise may lead to increased fatigue and exacerbation of MS symptoms. A personalized exercise plan that considers the individual's specific abilities and limitations is recommended.
Choice D reason
"Place a scatter rug in your bathroom to prevent falling" is not appropriate statement. Placing a scatter rug in the bathroom is not advisable, especially for individuals with mobility and balance issues like those with MS. Scatter rugs can create tripping hazards and increase the risk of falls. It is essential to keep the bathroom floor clear and use non-slip mats to improve safety.
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