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 C

Explanation

A. Some of the residents are wearing blankets around their shoulders to keep warm.

Explanation: While this indicates that some residents are taking measures to keep warm, it is more of an observation than a documentation of the overall impact of temperature on the health and well-being of all residents.

B. It feels much warmer in the administration wing than out in the client care areas.

Explanation: This statement relates to variations in temperature within the facility but does not directly address the suitability of the overall ambient temperature for the well-being of older adults.

C. An ambient temperature of 62°F is unsuitable for older people because they have impaired thermoregulation.

Explanation: Older adults often have impaired thermoregulation, making them more vulnerable to temperature extremes. A temperature of 62°F may be too cold for older adults, increasing the risk of hypothermia or discomfort. Addressing the potential impact of impaired thermoregulation on older individuals' health and well-being is crucial in maintaining a safe and comfortable environment.

D. It is not fair for older adults to have to deal with an uncomfortable environment.

Explanation: While fairness and comfort are valid considerations, the primary concern should be the potential impact of the ambient temperature on the health and well-being of older adults, especially considering their impaired thermoregulation.

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

The overall temperature in the gerontological unit is 62°F during the evening shift. In documenting this concern to the administration, which factor is the most important for the health and well-being of older adults?

Correct Answer is C

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

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