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 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.

A. Participants in Pace programs must be able to perform their own ADLs Independently. B. Participants in Pace programs must have been residents in a nursing home prior to enrollment in the Pace program. C. Participants in Pace programs must be eligible for either Medicare or Medicaid. D. Pace programs only provide service to individuals who are age 55 and over. E. Pace programs provide services to individuals who meet the criteria for nursing home admission

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

Explanation

A. Participants in PACE programs must be able to perform their own ADLs independently.

Explanation: This statement is generally not true. PACE programs are designed to provide comprehensive and coordinated care for individuals who are frail and meet the criteria for nursing home admission. The emphasis is on maintaining participants in their homes and communities. Participants in PACE programs often have limitations in Activities of Daily Living (ADLs), and the program is designed to support them in these activities.

B. Participants in PACE programs must have been residents in a nursing home prior to enrollment in the PACE program.

Explanation: This statement is generally not true. PACE programs aim to keep individuals out of nursing homes by providing comprehensive healthcare services in a community setting. Participants in PACE programs are often those at risk of nursing home placement due to their health and functional status.

C. Participants in PACE programs must be eligible for either Medicare or Medicaid.

Explanation: This statement is generally true. PACE programs are funded through Medicare and Medicaid. Participants must be eligible for both Medicare and Medicaid to enroll in a PACE program. Medicaid eligibility may vary by state.

D. PACE programs only provide service to individuals who are age 55 and over.

Explanation: This statement is generally true. PACE programs typically serve individuals who are 55 years of age or older. However, the specific age eligibility may vary by state.

E. PACE programs provide services to individuals who meet the criteria for nursing home admission.

Explanation: This statement is generally true. PACE programs are designed for individuals who are at risk of nursing home placement due to their health and functional status. Participants must meet the criteria for nursing home admission to be eligible for PACE services.

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Naxlex Comprehensive Predictor Exams

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

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

Explanation

To prevent malnutrition in older clients with dementia, which of the following would benefit your client? (Select all that apply.)

A health care provider asks the nurse about an older adult client's durable power of attorney (POA) because consent is needed for a medically necessary invasive procedure. The client has end-stage disease, is intubated, and is on mechanical ventilation. Which steps should the nurse implement?

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.)

Which of the following assessments should be included in a post fall prevention assessment of an older adult? (Select all that apply.)

As a nurse caring for a cognitively impaired older adult client, you need to observe for which of the following? (Select all that apply.)

A nurse counseling an 85-year-old person regarding modifying driving habits would include

Components to a cognitive assessment include which of the following? (Select all that apply.)