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 C
Explanation
A. Question-and-answer: This strategy involves the nurse asking questions to assess the client's understanding and provide information, but it does not involve the client performing the skill.
B. Role-play: Role-play involves the client acting out scenarios to practice skills, but this is not the method being described where the client is simply asked to perform a skill.
C. Return demonstration: This strategy involves the client performing a skill or procedure after being shown how to do it, allowing the nurse to assess the client's competence in the skill. This is the method being described in the scenario.
D. Discussion: Discussion involves talking through concepts or information but does not include the client actively performing a skill.
Correct Answer is B
Explanation
A. Change in marital status: This is a psychological and social stressor rather than a physiological one.
B. Burn injury: A burn injury is a physiological stressor because it directly affects the body's physical systems and functions, causing a stress response.
C. Academic pressure: This represents a psychological and emotional stressor, impacting mental health and well-being, rather than physical systems.
D. Financial difficulties: Financial difficulties are psychological and social stressors, affecting emotional and mental health rather than physiological processes.
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