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 ["A","B","D"]

Explanation

A. Comprehensive assessment

Explanation: A comprehensive assessment involves a thorough evaluation of various cognitive functions, including memory, attention, language, problem-solving, and executive functions. This allows for a comprehensive understanding of an individual's cognitive abilities.

B. Assessing for atypical presentation of illness

Explanation: Assessing for atypical presentation of illness is relevant in a cognitive assessment because some medical conditions or illnesses can manifest with cognitive symptoms. Recognizing atypical presentations helps in identifying potential underlying causes of cognitive changes.

C. Complete blood count

Explanation: While laboratory tests like a complete blood count (CBC) may be useful in identifying certain medical conditions that could affect cognition, it is not a direct component of a cognitive assessment. Cognitive assessments typically involve clinical interviews, neuropsychological testing, and observation of cognitive functions. Blood tests and other diagnostic tools may be used to complement the cognitive assessment but are not considered components of it.

D. Differentiating delirium, dementia, and depression

Explanation: Distinguishing between delirium, dementia, and depression is crucial in a cognitive assessment. Each condition has distinct characteristics, and accurate differentiation is necessary for appropriate intervention and management.

A. Constipation B. Poor solid food intake C. Poor liquid intake D. Diarrhea

Correct Answer is A

Explanation

A. Constipation is a common side effect of opioid medications like morphine. It is a priority to address because constipation can lead to discomfort, increased pain, and other complications. Preventive measures such as increased fiber intake, adequate hydration, and bowel regimen may be necessary.

B. Poor solid food intake and C. poor liquid intake are concerns, but they are secondary to the immediate issue of constipation. Adequate nutrition and hydration are important for overall recovery, but constipation can have more immediate and uncomfortable consequences.

D. Diarrhea is not a common side effect of morphine. In fact, constipation is a more common gastrointestinal side effect. If the patient were to experience diarrhea, it could be indicative of another issue or complication that needs to be addressed, but it is not the primary preventive care concern associated with morphine use.

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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

Components to a cognitive assessment include which of the following? (Select all that apply.)

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

Explanation

An older adult who is on bed rest after surgery is prescribed morphine for pain. Which of the following is the nurse's priority for preventive care?

Correct Answer is A

Explanation

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?

Which of the following statements are true about Medicare-part 8 supplemental insurance? (Select all that apply.)

Hypothermia is a medical emergency defined as a core temperature less than 95°F. Which of the following tips to prevent hypothermia should you tell your elderly client? (Select all that apply.)

A home health nurse is making a home visit to an older adult client. A nurse conducts a home safety assessment and screens the environment for potential hazards for falls. The nurse recommends that the client eliminate which of the following? (Select all that apply.)

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

The nurse assesses an older adult's cognitive status using a standard assessment instrument. Which of the following are cognitive assessment tools? (Select all that apply.)

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