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 D
Explanation
A. "As the health care proxy, you are the one who makes the decisions. Let's call your mom's doctor."
Explanation: This response inaccurately suggests that the health care proxy has the authority to make decisions even when the client has decision-making capacity. The focus should be on the client's autonomy.
B. "I understand why you are so upset. I don't think she is doing the right thing either. Let us think together how we can change her mind."
Explanation: This response is inappropriate as it involves the nurse expressing a personal opinion and attempting to influence the client's decision. The nurse's role is to support the client's autonomy and facilitate communication between the client and their family.
C. "You will need to go to court and be declared a guardian."
Explanation: Involving the court and seeking guardianship is not warranted when the client has decision-making capacity. This option is not aligned with the principles of respecting the client's autonomy and decision-making capacity.
D. "Health care proxies only come into play when the individual can no longer make their own decisions. Your mother is able to make her own decisions. I suggest you talk with her."
Explanation: In this scenario, the client is cognitively intact and has decision-making capacity. As long as the older adult is able to make their own decisions, the health care proxy's role is not activated. The nurse appropriately advises the daughter to communicate directly with her mother about her concerns and decisions. This respects the autonomy of the client, who has the right to make decisions about their own healthcare as long as they have the capacity to do so.
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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