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 C
Explanation
A. Because a conservatorship is the least restrictive alternative, a court hearing is not required.
Explanation: This statement is not accurate. Conservatorships are legal arrangements that involve the appointment of a conservator to manage the financial affairs and assets of an individual who is unable to do so themselves. While conservatorships may be necessary for the protection of the individual, they are not automatically considered the least restrictive alternative, and a court hearing is typically required to establish one.
B. The most legally restricting way individuals and property can be handled are through conservatorships and guardianships.
Explanation: This statement is partially true. Conservatorships and guardianships are legal mechanisms that grant authority to individuals (conservators and guardians, respectively) to manage the affairs of someone who is unable to do so themselves. While they involve legal restrictions, whether they are the most restrictive or not can depend on the specific details of the arrangement and the jurisdiction.
C. A conservatorship entails control over property, whereas a guardianship entails control over the person.
Explanation: This statement is true. In general, a conservatorship focuses on managing the financial affairs and assets of an individual, while a guardianship involves decision-making authority over personal and healthcare matters. The roles and responsibilities of conservators and guardians may vary by jurisdiction, but the distinction between control over property and control over the person is a common principle.
D. Conservators cannot be members of the conservatee's (client's) family.
Explanation: This statement is not universally true. In many cases, family members can be appointed as conservators. The court will typically consider the best interests of the individual in need of protection when appointing a conservator, and a family member may be deemed suitable if they can fulfill the responsibilities of the role. The specific rules regarding who can be a conservator may vary by jurisdiction.
Correct Answer is ["B","D"]
Explanation
B. Provide nutritious food according to the residents' expressed food preferences.
Explanation: Offering nutritious food based on residents' preferences can enhance their satisfaction with meals, making them more likely to eat and maintain adequate nutritional intake. Taking individual preferences into account helps create a more person-centered approach to nutrition.
D. Distribute "med-pass" nutritional supplements.
Explanation: Nutritional supplements may be beneficial for residents who have difficulty meeting their nutritional needs through regular meals. "Med-pass" supplements can be distributed with medications or as a separate supplement to enhance calorie and nutrient intake, especially for those with specific dietary requirements.
The other options are not recommended:
A. Develop a seating chart for the main dining room based on the unit to facilitate a more organized and efficient meal delivery.
Explanation: While organization and efficiency are important, creating a seating chart based on the unit might not directly address the nutritional status of residents. Instead, focus should be on providing appetizing, nutritious meals and accommodating residents' preferences.
C. Replace the fluorescent lighting with candles at every table to create a cozy, restaurant-like atmosphere.
Explanation: While creating a pleasant dining environment is important, replacing fluorescent lighting with candles may not be practical or safe in a healthcare setting. Moreover, the emphasis should be on the nutritional content of the meals rather than the ambiance.
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