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.

Nursing Test Bank

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Naxlex Comprehensive Predictor Exams

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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.

A. The Global Deterioration Scale B. Mini Mental State Exam (MMSE) C. Older American's Resources and Services (OARS) D. Mini-Cog E. The Barthel Index

Correct Answer is ["A","B","D"]

Explanation

A. The Global Deterioration Scale

Explanation: The Global Deterioration Scale (GDS) is a tool used to assess the cognitive function and stage of cognitive decline in individuals, especially those with dementia.

B. Mini Mental State Exam (MMSE)

Explanation: The Mini Mental State Exam (MMSE) is a widely used tool to assess cognitive function and screen for cognitive impairment. It evaluates various cognitive domains, including orientation, memory, attention, and language.

C. Older American's Resources and Services (OARS)

Explanation: The Older American's Resources and Services (OARS) is not a cognitive assessment tool. It is a comprehensive assessment tool that covers various domains, including physical health, mental health, and social resources.

D. Mini-Cog

Explanation: The Mini-Cog is a brief cognitive screening tool that includes a three-item recall test for memory and a clock-drawing task. It is used to quickly assess cognitive function and detect potential cognitive impairment.

E. The Barthel Index

Explanation: The Barthel Index is not a cognitive assessment tool. It is a tool used to assess an individual's ability to perform activities of daily living (ADLs), providing information about their functional independence rather than cognitive status.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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

Explanation

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.)

Correct Answer is ["A","B","D"]

Explanation

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?

Which is the fundamental difference between Medicare Part A and Medicare Part B?

An older adult client who was a veteran of World War II has just died. His widowed wife did not work and does not have sufficient funds to afford supplemental Medicare insurance. You would recommend which one of the following?

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.)

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.

The nurse wants to suggest exercise program options for an older client who is recovering losing her balance and falling. Which nursing intervention is suitable for this older adult?