The nurse assesses the quality of which of the following patient characteristics when applying the Get-Up-and-Go test from the Hendrich II Fall Risk Model?

Balance

Stride

Flexibility

Speed

Answer and Explanation

The Correct Answer is A

A. Balance:

The Get-Up-and-Go test assesses the patient's ability to maintain balance during the process of standing up from a chair, walking a short distance, turning around, and sitting down. Impaired balance can be a significant risk factor for falls.

B. Stride:

Stride, or the length of a person's step, is not explicitly assessed in the Get-Up-and-Go test. However, the test may indirectly provide information about the patient's walking pattern and step characteristics.

C. Flexibility:

While flexibility is not a specific focus of the Get-Up-and-Go test, the test involves movements that require a degree of joint flexibility, such as bending the knees to stand up and sit down.

D. Speed:

Speed is an important aspect of the Get-Up-and-Go test. The time taken by the patient to complete the entire sequence of standing up, walking, turning, and sitting down is considered. Slower performance on the test may indicate an increased risk of falls.

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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.

A. Four -length rails B. One-length rail C. Two full-length rails D. No side rails

Correct Answer is B

Explanation

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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The nurse assesses the quality of which of the following patient characteristics when applying the Get-Up-and-Go test from the Hendrich II Fall Risk Model?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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

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?

Correct Answer is B

Explanation

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