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 ["B","C"]
Explanation
A. Night lights
Explanation: Night lights can enhance visibility during nighttime, reducing the risk of falls. The nurse may actually recommend using night lights strategically to illuminate pathways, especially in areas like hallways and bathrooms.
B. Excess clutter
Explanation: Excess clutter on floors can increase the risk of tripping and falling. Removing or organizing clutter helps create a safer environment for the older adult.
C. Loose carpeting on the floors
Explanation: Loose or wrinkled carpeting poses a tripping hazard. The nurse may recommend securing or replacing loose carpeting to prevent falls.
D. Railings on the stairway
Explanation: Railings on stairways are important safety features that provide support and stability. The nurse would likely recommend maintaining or installing railings to enhance stair safety.
E. The use of a cane
Explanation: If prescribed by a healthcare professional, the use of a cane can improve stability and balance for an older adult. The nurse may not recommend eliminating the use of a cane but may instead ensure that the client is using it correctly and that it is in good condition.
Correct Answer is A
Explanation
A. A standard assessment tool will increase the likelihood of obtaining accurate data.
Explanation: Standardized assessment tools, like the Mini-Cog, are designed to provide consistent and objective measures of specific aspects of a client's health, in this case, mental status. Using such tools helps ensure a standardized and systematic approach to data collection, increasing the reliability and accuracy of the information gathered. This, in turn, contributes to a more comprehensive understanding of the client's health status.
B. A standard assessment tool is required by Medicare and Medicaid.
Explanation: While some standardized assessment tools may be recommended or required by certain healthcare agencies or institutions, there isn't a broad requirement from Medicare and Medicaid for a specific tool. The use of assessment tools may vary based on clinical judgment and institutional policies.
C. A standard assessment tool will increase reimbursement by Medicare and Medicaid.
Explanation: The use of a specific assessment tool is not a direct factor that influences reimbursement by Medicare and Medicaid. Reimbursement is typically based on the overall care provided and documented, rather than the specific assessment tool used.
D. A standard assessment tool will increase the client's confidence in the nurse.
Explanation: While utilizing a standard assessment tool may contribute to the overall professionalism and thoroughness of care, the primary purpose is to obtain accurate and objective data rather than specifically increasing the client's confidence in the nurse. Confidence is often influenced by the nurse's communication, empathy, and overall competence in providing care.
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