An elderly patient, who is ambulatory and independent, is admitted to the hospital. What intervention by the nurse would be most effective in preventing falls for this patient?

Arrange for a bedside commode for the patient.

Ensure the bathroom light is kept on during the night.

Use side rails to keep the patient in bed.

Implement a toileting schedule for the patient.

Answer and Explanation

The Correct Answer is D

Rationale for Choice A:

Arranging for a bedside commode can be helpful for patients who have difficulty ambulating to the bathroom. However, it is not the most effective intervention for preventing falls in an ambulatory and independent patient. In fact, it could potentially increase the risk of falls if the patient attempts to use the commode without assistance or if they become disoriented in the dark.

Research has shown that bedside commodes are associated with an increased risk of falls in hospitalized patients. This is because patients may try to get out of bed to use the commode without assistance, or they may become disoriented in the dark and fall.

Additionally, bedside commodes can be a tripping hazard, especially for patients with impaired mobility.

Rationale for Choice B:

Ensuring the bathroom light is kept on during the night can help to reduce the risk of falls by making it easier for the patient to see. However, it is not the most effective intervention for preventing falls.

Patients may still fall even if the bathroom light is on, especially if they are weak, unsteady, or have impaired vision. Additionally, keeping the bathroom light on all night can disrupt the patient's sleep, which can also increase the risk of falls.

Rationale for Choice C:

Using side rails to keep the patient in bed is not an effective intervention for preventing falls. In fact, it can actually increase the risk of falls by making it more difficult for the patient to get out of bed safely.

Patients may try to climb over the side rails, which can lead to falls.

Additionally, side rails can restrict the patient's movement and make them feel trapped, which can lead to agitation and an increased risk of falls.

Rationale for Choice D:

Implementing a toileting schedule is the most effective intervention for preventing falls in an ambulatory and independent patient. This is because it helps to reduce the patient's need to get out of bed at night to use the bathroom.

When a patient has a scheduled time to toilet, they are less likely to try to get out of bed on their own and risk a fall. Additionally, a toileting schedule can help to prevent incontinence, which can also lead to falls.

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Correct Answer is B

Explanation

Choice A rationale:
Massaging the site with scented oils is not recommended for pain relief after removal of a peripheral vascular access device. There is no evidence to support the effectiveness of scented oils in this context.
Additionally, some scented oils can be irritating to the skin, which could potentially worsen the pain, redness, and swelling.
It's crucial to use products that are specifically designed for wound care and pain management, and to follow the healthcare provider's instructions.
Choice B rationale:
Applying warm compresses to the site is an effective and recommended intervention to alleviate pain, redness, and swelling after removal of a peripheral vascular access device.
Warm compresses have the following beneficial effects:
Vasodilation: They promote blood flow to the area, which helps to reduce inflammation and pain. Muscle relaxation: The warmth helps to relax tense muscles, further easing discomfort.
Pain relief: Warmth can directly inhibit pain signals, providing a soothing sensation.
Increased circulation: Improved blood flow can help to remove inflammatory substances and promote healing. It's important to use a clean, warm compress and to apply it for 15-20 minutes at a time, several times a day.
Choice C rationale:
Topical lidocaine is a local anesthetic that can temporarily numb the skin.
While it can be used for pain relief, it's not typically the first-line intervention for pain associated with removal of a peripheral vascular access device.
Warm compresses are often preferred as they provide a more natural and non-invasive approach to pain management.
Choice D rationale:
Oral pain medication may be necessary if warm compresses do not provide adequate pain relief.
However, it's important to follow the healthcare provider's instructions regarding the type and dosage of pain medication to use.
Over-the-counter pain relievers, such as acetaminophen or ibuprofen, may be sufficient in some cases. Stronger prescription pain medication may be needed for more severe pain.

A. Antibiotics are typically required for 14 to 21 days for Stage I disease. B. A red rash resembling a bull’s eye may be one of the symptoms. C. If Lyme disease is not successfully treated, it is usually fatal. D. Precautions against ticks should be taken, especially in the summer.

Correct Answer is C

Explanation

Choice A rationale:
This statement is accurate. Early Lyme disease (Stage I) is typically treated with oral antibiotics for 14 to 21 days. This is often effective in clearing the infection and preventing further complications.
Choice B rationale:
This statement is also accurate. A red rash that may resemble a bull's eye is a common early symptom of Lyme disease. It often appears at the site of the tick bite, typically within 3 to 30 days after the bite.
Choice C rationale:
This statement is incorrect. While Lyme disease can be serious if not treated, it is rarely fatal. Most people who are treated for Lyme disease recover fully. However, if left untreated, it can lead to chronic health problems, such as arthritis, neurological problems, and heart issues.
Choice D rationale:
This statement is accurate. Taking precautions against tick bites is essential for preventing Lyme disease. Ticks are most active during the warmer months, so it's crucial to be vigilant about tick prevention during the spring, summer, and fall.

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An elderly patient, who is ambulatory and independent, is admitted to the hospital. What intervention by the nurse would be most effective in preventing falls for this patient?

Rationale for Choice A:

Rationale for Choice B:

Rationale for Choice D:

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is attending to a client with a peripheral vascular access device who is experiencing pain, redness, and swelling at the site. What action should the nurse take to alleviate the pain after removing the device?

Correct Answer is B

Explanation

A nurse has conducted an educational session for a community group on Lyme disease. Which statement by a participant indicates a need for further review of the material?

Correct Answer is C

Explanation

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