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 D

Explanation

A. HIPAA (Health Insurance Portability and Accountability Act)

Explanation: HIPAA, enacted in 1996, focuses on protecting the privacy and security of individuals' health information. While it is essential in healthcare, it is not directly connected to the nursing home reform mandated by the 1987 law.

B. OASIS (Outcome and Assessment Information Set)

Explanation: OASIS is a set of standardized assessments used in home health care, primarily for Medicare-certified home health agencies. It is not directly connected to the nursing home reform mandated by the 1987 law.

C. Fulmer SPICES

Explanation: Fulmer SPICES is a tool used for assessing common geriatric syndromes, but it is not specifically associated with the nursing home reform mandated by the 1987 law.

D. Resident Assessment Instrument (RAI).

Explanation: The Resident Assessment Instrument (RAI) is associated with nursing home reform mandated by the Omnibus Budget Reconciliation Act (OBRA) of 1987. OBRA '87 established regulations and standards for nursing homes, including requirements for comprehensive assessments, care planning, and quality of care. The RAI, specifically the Minimum Data Set (MDS), is a standardized assessment tool used to evaluate the health status and needs of nursing home residents, ensuring a consistent and comprehensive approach to resident assessment and care planning.

A. The conservator will function in the same capacity as a health care proxy B. This client does not have the capacity to give informed consent for any procedures C. The presence of a conservator does not mean the client cannot give informed consent D. The needs to provide all educational materials to the conservator instead of the client

Correct Answer is C

Explanation

A. The conservator will function in the same capacity as a health care proxy.
Explanation: A conservator and a health care proxy serve different roles. A conservator is appointed by a court to manage financial affairs, while a health care proxy is designated to make medical decisions on behalf of the individual if they are unable to do so. These roles are not interchangeable.

B. This client does not have the capacity to give informed consent for any procedures.
Explanation: The presence of a conservator alone does not automatically indicate a lack of capacity to give informed consent. Capacity for making healthcare decisions is determined on an individual basis and may vary depending on the client's cognitive and decision-making abilities.

C. The presence of a conservator does not mean the client cannot give informed consent.
Explanation: Having a court-appointed conservator to manage finances does not automatically imply that the client lacks the capacity to provide informed consent for medical procedures. The ability to make healthcare decisions, including giving informed consent, is distinct from financial capacity. Even if a conservator is appointed for financial matters, the client may still have the capacity to participate in decisions related to their health and medical treatment.

D. The nurse needs to provide all educational materials to the conservator instead of the client.
Explanation: Educational materials related to the client's healthcare should be provided directly to the client whenever possible. While the conservator may be involved in financial matters, the client should still receive relevant information regarding their health and medical care.

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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 one of the following is connected with the nursing home reform mandated by a 1987 law?

Correct Answer is D

Explanation

An older client is admitted to the hospital for treatment of pneumonia. The client has a court appointed conservator who manages her finances. The nurse understands what fact about the situation?

Correct Answer is C

Explanation

What are the benefits associated with telehealth technology? (Select all that apply.)

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.)

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?

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.)

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.)

The Bill of Rights for long-term residents was created to protect the rights of the residents in nursing homes. Which of the following examples protect these rights? (Select all that apply.)

The nurse should encourage which of the following exercise(s) to assist with balance for a client who is at high risk for falls? (Select all that apply.