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

Explanation

A. Defecation less than once each day is not necessarily constipation.

Explanation: The frequency of bowel movements varies among individuals, and defecating less than once each day does not necessarily indicate constipation. Normal bowel habits can differ, and what is considered regular for one person may not be the same for another. Constipation is better assessed by considering other factors such as stool consistency, straining during bowel movements, and feelings of incomplete evacuation.

B. Leaking liquid feces should be treated as diarrhea.

Explanation: Leaking liquid feces may be indicative of diarrhea, but it is not the only factor to consider. The cause of diarrhea should be investigated, and treatment will depend on the underlying reason, which may include infections, medications, or other medical conditions.

C. Mineral oil is recommended as a laxative for the older adult.

Explanation: Mineral oil is generally not recommended as a laxative for older adults. It can interfere with the absorption of fat-soluble vitamins and may have adverse effects. There are other safer and more effective laxative options that healthcare providers may recommend.

D. Excessive sleep can be a symptom of constipation.

Explanation: Excessive sleep is not typically considered a symptom of constipation. Constipation is more commonly associated with symptoms such as infrequent bowel movements, difficulty passing stool, and abdominal discomfort. Sleep disturbances may have various causes, but they are not a direct symptom of constipation.

A. To improve the quality of care B. To evaluate the level of client disability C. To improve the communication about the individual D. To serve as a guide for reimbursement

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

Explanation

A. To improve the quality of care

Explanation: The OASIS assessment is designed to gather information about a patient's health status, functional abilities, and service needs. This information is crucial for developing individualized care plans and providing high-quality care.

B. To evaluate the level of client disability

Explanation: OASIS includes items that assess various aspects of a patient's health, including their functional abilities and disabilities. This evaluation helps healthcare providers understand the client's level of disability and tailor care accordingly.

C. To improve communication about the individual

Explanation: OASIS serves as a standardized tool for collecting and communicating essential information about a patient's health and care needs. This promotes effective communication among healthcare providers, ensuring that everyone involved in the patient's care has access to relevant and consistent information.

D. To serve as a guide for reimbursement

Explanation: OASIS is used in the home health care setting to guide reimbursement. The data collected through OASIS is used to determine the patient's case-mix classification, which, in turn, influences the reimbursement rates for home health services.

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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

Which of the following is a true statement about elimination in older adults?

Correct Answer is A

Explanation

The OASIS was implemented to provide the format for a comprehensive assessment in the home health care setting. How is this assessment tool used? (Select all that apply.)

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

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.)

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.)

The nurse is trying to improve the nutritional status of residents in the nursing home. Which recommendations 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?

A nurse counseling an 85-year-old person regarding modifying driving habits would include

A resident's family member is concerned that the resident is not eating adequately and is at risk for malnutrition. The family member says to a nurse, "I heard that there are drugs that can make my mother eat better. Do you think she should be on one?" What is the best response by the nurse?