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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Free Nursing Study Resources

Correct Answer is ["A","B","C","D","E"]

Explanation

A. Pointing to a grimacing face or crying

Explanation: This behavior may indicate pain or discomfort, and it's important to assess and address the underlying cause.

B. Staring off into space

Explanation: Staring off into space may suggest disorientation or confusion. It's essential to evaluate whether this behavior is a manifestation of the client's cognitive impairment or if there are other contributing factors.

C. Aggression

Explanation: Aggression can be a behavioral expression of distress or frustration in cognitively impaired individuals. Identifying triggers and employing appropriate interventions is crucial for the safety of the client and others.

D. Agitation

Explanation: Agitation, restlessness, or pacing may be signs of discomfort, anxiety, or frustration in cognitively impaired individuals. Identifying the cause and implementing strategies to reduce agitation are essential aspects of care.

E. Increased confusion

Explanation: A sudden increase in confusion may indicate an underlying issue, such as an infection, medication side effect, or environmental change. Regular assessment of cognitive status helps in detecting changes and addressing them promptly.

F. Decreased passivity

Explanation: Passivity, or a lack of activity or initiative, is not necessarily a specific symptom commonly associated with cognitive impairment. Observing for changes in behavior, mood, and cognitive status is important, but the term "decreased passivity" is not a standard indicator of cognitive impairment. Instead, it's essential to assess for changes in behavior that may indicate distress or unmet needs.

A. Hearing B. Vision C. Cognitive disorders D. Preprandial hypotension E. Orthostatic hypotension

Correct Answer is ["B","C","D","E"]

Explanation

A. Hearing.

While hearing impairment can affect overall awareness, it is not as directly linked to the risk of falls as vision, cognitive disorders, and blood pressure-related issues.

B. Vision.

Correct. Visual impairment can contribute to an increased risk of falls.

C. Cognitive disorders.

Correct. Cognitive impairment or disorders can impact a person's awareness and ability to navigate their environment safely.

D. Preprandial hypotension.

Correct. Low blood pressure before meals (preprandial hypotension) can contribute to dizziness and falls, especially in older adults.

E. Orthostatic hypotension.

Correct. Orthostatic hypotension, a drop in blood pressure upon standing, is a risk factor for falls.

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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

As a nurse caring for a cognitively impaired older adult client, you need to observe for which of the following? (Select all that apply.)

Correct Answer is ["A","B","C","D","E"]

Explanation

When assessing your client who has a history of falls, you should pay particular attention to which of the following? (Select all that apply.)

Correct Answer is ["B","C","D","E"]

Explanation

Which of the following assessments should be included in a post fall prevention assessment of an older adult? (Select all that apply.)

What components are included in a person-centered community? (Select all that apply.)

A nurse is assessing an older adult's nutritional status. The nurse understands that which of the following is the most important indicator for a potential nutritional deficit?

A client care assistant has been assigned to feed your female client with dysphagia. Which of the following instructions would you give the assistant? (Select all that apply.)

An older adult client who was a veteran of World War II has just died. His widowed wife did not work and does not have sufficient funds to afford supplemental Medicare insurance. You would recommend which one of the following?

Which attempt by the family to prevent an older frail adult from falling causes the home health nurse concern?

A health care provider asks the nurse about an older adult client's durable power of attorney (POA) because consent is needed for a medically necessary invasive procedure. The client has end-stage disease, is intubated, and is on mechanical ventilation. Which steps should the nurse implement?

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