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. Keeps room temperature at 72°F.

Explanation: Maintaining a room temperature of 72°F is generally considered comfortable and is not likely to contribute to hyperthermia, especially when compared to higher temperatures. However, it's essential to consider individual preferences and comfort levels.

B. Has a history of osteoarthritis.

Explanation: Osteoarthritis itself is not directly associated with an increased risk of hyperthermia. However, limitations in mobility or difficulties with self-care due to osteoarthritis might indirectly impact the ability to stay cool and hydrated, so comprehensive care should consider the overall health status of the individual.

C. Takes furosemide 40 mg daily.

Explanation: Furosemide is a diuretic that increases urine production, leading to fluid loss. Dehydration or electrolyte imbalances resulting from diuretic use can contribute to an increased risk of hyperthermia, especially in hot weather. It's important for healthcare providers to monitor and manage medications, considering their potential effects on fluid balance and thermoregulation.

D. Bathes daily with a hot shower.

Explanation: While taking hot showers may contribute to temporary elevation of body temperature, bathing alone may not be a significant contributor to hyperthermia. However, if an older adult has difficulty tolerating heat or maintaining hydration, it's essential to consider the cumulative impact of various factors.

A. Provide a urinal and drinking water. B. Call for someone to bring the sign. C. Instruct the client to use call bell for help. D. Ensure he can reach his personal items

Correct Answer is C

Explanation

A. Provide a urinal and drinking water.

Explanation: While providing a urinal and drinking water is important for the client's comfort and hydration, it may not directly address the risk of falls in this situation.

B. Call for someone to bring the sign.

Explanation: Bringing a fall risk sign is a secondary measure and not as immediate as instructing the client to use the call bell. The priority is to ensure the client's safety by addressing the need for assistance promptly.

C. Instruct the client to use the call bell for help.

Explanation: Instructing the client to use the call bell for help is a crucial intervention to ensure that the client can request assistance when needed. Promptly responding to the call bell allows healthcare providers to assist the client with activities such as getting out of bed, using the bathroom, or reaching personal items without the risk of falls. Educating and encouraging clients to use the call bell empowers them to seek assistance and promotes their safety.

D. Ensure he can reach his personal items.

Explanation: Ensuring the client can reach personal items is part of providing a comfortable environment but may not prevent falls. The critical factor in fall prevention is promoting communication and the ability to request assistance in a timely manner.

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Naxlex Comprehensive Predictor Exams

Which patient assessment data does the nurse recognize could contribute to an older adult's risk of hyperthermia?

Correct Answer is C

Explanation

Correct Answer is C

Explanation

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

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

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

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:

When assessing your client who has a history of falls, you should pay particular attention to which of the following? (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.)