The client has been admitted and placed on fall precautions. The nurse explains to the patient that interventions for the precautions include: (Select All that Apply)
Placing a high risk for falls armband on the patient
Checking on the patient once a shift
Keep the bed in the lowest position
Placing all four side rails in the "up" position
Maintain call light within reach of the patient
Correct Answer : A,C,E
A. Placing a high risk for falls armband on the patient: An armband alerts all healthcare providers to the patient's fall risk, helping to ensure appropriate precautions are taken.
B. Checking on the patient once a shift: This is not sufficient; patients on fall precautions should be checked more frequently, such as every hour or according to the facility's protocol, to ensure their safety.
C. Keep the bed in the lowest position: Keeping the bed at its lowest position reduces the risk of injury from falls and helps ensure the patient can easily get in and out of bed.
D. Placing all four side rails in the "up" position: Using all four side rails is not recommended as it can increase the risk of entrapment and may not be effective in preventing falls. Side rails should be used appropriately and in accordance with safety protocols.
E. Maintain call light within reach of the patient: Ensuring the call light is within reach helps the patient call for assistance if needed, which can help prevent falls.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["B","C","D"]
Explanation
A. Remove the dentures from the body: Dentures should typically be left in place unless otherwise directed, as removing them can alter the appearance of the deceased and may be distressing for the family.
B. Dim the lights in the room: Dimming the lights can create a more respectful and soothing environment for the family during their time of mourning.
C. Remove all equipment from the bedside: Removing equipment ensures a clear and respectful presentation of the body, allowing the family to view their loved one without distractions.
D. Apply fresh linens and place a clean gown on the body: This action helps present the body in a respectful manner, making it more presentable for the family.
E. Make sure the body is lying completely flat: The body should be positioned appropriately based on the clinical setting and family preferences, but the focus should be on creating a respectful and dignified presentation rather than strictly ensuring the body is completely flat.
Correct Answer is D
Explanation
A. Episodic acute stress: This term is not a recognized diagnosis. Acute stress disorder and posttraumatic stress disorder are the established diagnoses related to trauma and stress.
B. Irritable bowel syndrome (IBS): IBS is a gastrointestinal disorder characterized by abdominal pain and altered bowel habits. It is not related to the flashbacks of traumatic events.
C. Acute stress disorder (ASD): ASD occurs within the first month after exposure to a traumatic event and involves symptoms like intrusive memories and flashbacks. However, since the traumatic event occurred a year ago, this disorder is less likely than PTSD.
D. Posttraumatic stress disorder (PTSD): PTSD is characterized by symptoms such as flashbacks, nightmares, and severe anxiety following exposure to a traumatic event. Given the traumatic event happened a year ago, the client’s symptoms are consistent with PTSD.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.