A nurse admitting and orienting an older adult to the hospital unit discusses fall prevention and demonstrates the use of the call bell to the patient. The patient's daughter asks: "Why don't you just put up all the side rails to prevent my mother from getting out of bed by herself and falling. That should work, right?" What is the nurse's best response?

"Side rails do not decrease falls, but they do decrease fall related injuries."

"There is no evidence that side rail use decreases falls, and in fact, there is a greater risk of injury."

"Side rails are only effective when used with patients who have dementia"

Side rails have only proven to be effective in decreasing falls in patients who have already fallen."

Answer and Explanation

The Correct Answer is B

A. "Side rails do not decrease falls, but they do decrease fall-related injuries."

Explanation: While side rails may reduce the severity of injuries if a fall occurs, they are not proven to decrease the overall rate of falls. Additionally, side rails themselves can pose risks, including entrapment.

B. There is no evidence that side rail use decreases falls, and in fact, there is a greater risk of injury."

Explanation: The use of side rails as a fall prevention measure has been associated with risks and has not been shown to effectively decrease the overall rate of falls. There is evidence that side rails can contribute to injuries, including entrapment, when patients attempt to climb over or through them. The focus in fall prevention has shifted towards individualized assessments, environmental modifications, and other strategies that address the specific needs and risks of each patient.

C. "Side rails are only effective when used with patients who have dementia."

Explanation: The effectiveness of side rails is not limited to patients with dementia. However, the use of side rails as a general fall prevention strategy has been questioned, and their use should be carefully considered based on individual assessments and risks.

D. "Side rails have only proven to be effective in decreasing falls in patients who have already fallen."

Explanation: The use of side rails is not universally proven to be effective in decreasing falls, even in patients who have previously fallen. The decision to use side rails should be based on a thorough assessment of the individual's needs and risks, considering alternatives to promote safety.

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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. Two servings of deep-colored fruit B. Six or more servings of fortified, enriched, or whole grain foods C. Three or more servings of low-fat or nonfat dairy products D. Three 8 ounce glasses of water E. Four or more servings of high quality protein F. One or two servings of brightly colored vegetables

Correct Answer is ["B","C","D","E"]

Explanation

A. Two servings of deep-colored fruit.

While fruits are recommended, the "deep-colored" specification is not a specific focus in the MyPlate for Older Adults.

B. Six or more servings of fortified, enriched, or whole grain foods.

Correct. Whole grains are an important source of fiber, vitamins, and minerals.

C. Three or more servings of low-fat or nonfat dairy products.

Correct. Dairy products provide calcium and vitamin D, important for bone health.

D. Three 8-ounce glasses of water.

Correct. Staying hydrated is crucial for overall health, especially for older adults.

E. Four or more servings of high-quality protein.

Correct. Protein is essential for muscle maintenance and repair. Sources of high-quality protein include lean meats, poultry, fish, eggs, dairy, and plant-based protein sources.

F. One or two servings of brightly colored vegetables.

While vegetables are recommended, the "brightly colored" specification is not a specific focus in the MyPlate for Older Adults.

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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

Which recommendations for daily food intake is correct for older adults according to the MyPlate for Older Adults? (Select all that apply.)

Correct Answer is ["B","C","D","E"]

Explanation

Which of the following is a true statement about elimination in older adults?

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.

A resident's family member is concerned that the resident is not eating adequately and is at risk for malnutrition. The family member says to a nurse, "I heard that there are drugs that can make my mother eat better. Do you think she should be on one?" What is the best response by the nurse?

A nurse is assessing an older adult's nutritional status. The nurse understands that which of the following is the most important indicator for a potential nutritional deficit?

A home health nurse is making a home visit to an older adult client. A nurse conducts a home safety assessment and screens the environment for potential hazards for falls. The nurse recommends that the client eliminate which of the following? (Select all that apply.)

An older client is being discharged from the hospital to a sub-acute unit. The client says to a nurse, "I am not sure I understand the difference between a sub-acute unit and a nursing home. Can you help me understand?" The nurse considers which of the following in formulating a response: