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 B

Explanation

A. He is able to name objects with which he comes in contact correctly.

Explanation: Being able to name objects correctly indicates intact language and object recognition skills, which are positive aspects of cognitive function.

B. He is constantly checking to see whether what he did is correct.

Explanation: Constantly checking to see whether what he did is correct may be an indicator of anxiety or uncertainty about cognitive performance. While this behavior alone does not confirm cognitive impairment, it raises a question about the individual's confidence or potential challenges in decision-making.

C. He is able to hold a conversation with you.

Explanation: Holding a conversation demonstrates language and communication abilities, suggesting intact cognitive skills for social interaction.

D. His attention span will last as long as the project he is working on.

Explanation: Having an attention span that matches the duration of a project suggests a focused and goal-oriented approach, which can be a positive aspect of cognitive function.

A. Age-related motor deficiencies that result in self-neglect B. Age-related neurosensory changes that diminish awareness of temperature changes C. Delirium-related to an acute illness that is affecting body heat production D. Cognitive changes that diminish the individual's awareness of temperature changes

Correct Answer is B

Explanation

A. Age-related motor deficiencies that result in self-neglect.

Explanation: While age-related motor deficiencies could potentially impact a person's ability to dress appropriately, the specific scenario described (wearing a sweater despite high temperatures) is more indicative of sensory awareness issues rather than motor deficiencies.

B. Age-related neurosensory changes that diminish awareness of temperature changes.

Explanation: As individuals age, there can be neurosensory changes that affect their ability to perceive temperature accurately. This can result in older adults being less aware of changes in temperature, leading to behaviors such as dressing inappropriately for the weather. In this scenario, the client wearing a sweater despite the high temperature outside may be attributed to diminished awareness of the actual environmental temperature.

C. Delirium related to an acute illness that is affecting body heat production.

Explanation: Delirium may indeed affect a person's cognitive and functional abilities, but the scenario does not provide evidence of delirium or an acute illness. The focus is on the client's behavior related to dressing inappropriately for the weather, which is more suggestive of sensory awareness issues.

D. Cognitive changes that diminish the individual's awareness of temperature changes.

Explanation: This option is similar to the correct answer (Option B). Cognitive changes, particularly in awareness, can contribute to inappropriate dressing for the weather in older adults. The primary distinction here is that the term "neurosensory changes" in Option B specifically highlights alterations in sensory perception.

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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

In assessing an older adult, you question his cognitive skills when you notice that

Correct Answer is B

Explanation

A 79-year-old client resides independently in the community. The visiting home health nurse finds that despite it being 90°F outside, the windows are closed and the client is wearing a sweater. The nurse initially recognizes that this behavior may be related to what?

Correct Answer is B

Explanation

Which option is part of a program that addresses bowel incontinence in an older adult client?

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

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?

A nurse conducts a comprehensive assessment of an older adult client. The nurse utilizes the Mini-Cog, a valid and reliable assessment tool to assess the individual's mental status. The nurse understands that the benefit of utilizing a standard assessment tool is what?

To prevent malnutrition in older clients with dementia, which of the following would benefit your client? (Select all that apply.)

The nurse wants to suggest exercise program options for an older client who is recovering losing her balance and falling. Which nursing intervention is suitable for this older adult?

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?

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