The health care provider has not ordered the use of a restraint for an alert patient at high risk for falling. The nurse should implement which side rail use?

Four -length rails

One-length rail

Two full-length rails

No side rails

Answer and Explanation

The Correct Answer is B

A. Four-length rails.

Explanation: Four-length rails fully enclose the bed and can be considered a more restrictive measure. They may be used when a restraint order is in place, but for an alert patient without such an order, less restrictive alternatives are preferred.

B. One-length rail.

Explanation: Using one-length rails can be a less restrictive alternative when a patient is at high risk for falling. The use of one side rail allows for some protection against falls without fully restraining the patient. This approach helps maintain the patient's mobility and autonomy while still providing a safety measure.

C. Two full-length rails.

Explanation: While using two full-length rails is less restrictive than four-length rails, it is still more restrictive than using only one side rail. The goal is to balance fall prevention with the patient's autonomy.

D. No side rails.

Explanation: Using no side rails may not provide adequate protection for an alert patient at high risk for falling. While avoiding restraints is essential, implementing at least one side rail is a reasonable compromise to enhance safety without fully restricting the patient's movement.

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Correct Answer is C

Explanation

A. Keeps room temperature at 72°F.

Explanation: Maintaining a room temperature of 72°F is generally considered comfortable and is not likely to contribute to hyperthermia, especially when compared to higher temperatures. However, it's essential to consider individual preferences and comfort levels.

B. Has a history of osteoarthritis.

Explanation: Osteoarthritis itself is not directly associated with an increased risk of hyperthermia. However, limitations in mobility or difficulties with self-care due to osteoarthritis might indirectly impact the ability to stay cool and hydrated, so comprehensive care should consider the overall health status of the individual.

C. Takes furosemide 40 mg daily.

Explanation: Furosemide is a diuretic that increases urine production, leading to fluid loss. Dehydration or electrolyte imbalances resulting from diuretic use can contribute to an increased risk of hyperthermia, especially in hot weather. It's important for healthcare providers to monitor and manage medications, considering their potential effects on fluid balance and thermoregulation.

D. Bathes daily with a hot shower.

Explanation: While taking hot showers may contribute to temporary elevation of body temperature, bathing alone may not be a significant contributor to hyperthermia. However, if an older adult has difficulty tolerating heat or maintaining hydration, it's essential to consider the cumulative impact of various factors.

A. It provides monetary benefits to American citizens and legal residents to prevent their dependency on their families B. It provides a minimum level of economic support. C. It is designed to help the states defray the expenses for the poor. D. It is meant to provide insurance coverage for medical care to the older adult and disabled populations, regardless of their financial situations

Correct Answer is C

Explanation

A. This statement is not entirely accurate. While Medicaid does provide assistance to eligible individuals, its primary focus is on healthcare coverage rather than offering general monetary benefits.

B. Medicaid is more focused on providing healthcare support rather than offering a minimum level of economic support. Its primary aim is to help cover medical expenses for eligible individuals.

C. Medicaid is designed to help the states defray the expenses for the poor.

Medicaid is a joint federal and state program that assists with medical costs for people with low income, including some low-income adults, children, pregnant women, elderly adults, and people with disabilities.

D. This statement is partially correct but doesn't encompass the full scope of Medicaid. Medicaid provides healthcare coverage for low-income individuals, including the older adult and disabled populations, but it also includes other eligible groups.

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The health care provider has not ordered the use of a restraint for an alert patient at high risk for falling. The nurse should implement which side rail use?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Which patient assessment data does the nurse recognize could contribute to an older adult's risk of hyperthermia?

Correct Answer is C

Explanation

In reviewing an older adult's insurance history, you find that he is on Medicaid. What do you know that Medicaid is used for?

Correct Answer is C

Explanation

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