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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Some of the residents are wearing blankets around their shoulders to keep warm.
Explanation: While this indicates that some residents are taking measures to keep warm, it is more of an observation than a documentation of the overall impact of temperature on the health and well-being of all residents.
B. It feels much warmer in the administration wing than out in the client care areas.
Explanation: This statement relates to variations in temperature within the facility but does not directly address the suitability of the overall ambient temperature for the well-being of older adults.
C. An ambient temperature of 62°F is unsuitable for older people because they have impaired thermoregulation.
Explanation: Older adults often have impaired thermoregulation, making them more vulnerable to temperature extremes. A temperature of 62°F may be too cold for older adults, increasing the risk of hypothermia or discomfort. Addressing the potential impact of impaired thermoregulation on older individuals' health and well-being is crucial in maintaining a safe and comfortable environment.
D. It is not fair for older adults to have to deal with an uncomfortable environment.
Explanation: While fairness and comfort are valid considerations, the primary concern should be the potential impact of the ambient temperature on the health and well-being of older adults, especially considering their impaired thermoregulation.
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.
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