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 D

Explanation

A. "As the health care proxy, you are the one who makes the decisions. Let's call your mom's doctor."
Explanation: This response inaccurately suggests that the health care proxy has the authority to make decisions even when the client has decision-making capacity. The focus should be on the client's autonomy.

B. "I understand why you are so upset. I don't think she is doing the right thing either. Let us think together how we can change her mind."
Explanation: This response is inappropriate as it involves the nurse expressing a personal opinion and attempting to influence the client's decision. The nurse's role is to support the client's autonomy and facilitate communication between the client and their family.

C. "You will need to go to court and be declared a guardian."
Explanation: Involving the court and seeking guardianship is not warranted when the client has decision-making capacity. This option is not aligned with the principles of respecting the client's autonomy and decision-making capacity.

D. "Health care proxies only come into play when the individual can no longer make their own decisions. Your mother is able to make her own decisions. I suggest you talk with her."
Explanation: In this scenario, the client is cognitively intact and has decision-making capacity. As long as the older adult is able to make their own decisions, the health care proxy's role is not activated. The nurse appropriately advises the daughter to communicate directly with her mother about her concerns and decisions. This respects the autonomy of the client, who has the right to make decisions about their own healthcare as long as they have the capacity to do so.

A. Decreased serum albumin levels B. Decreased vitamin D levels C. Unintentional weight loss, D. Anorexia lasting more than 24 hours

Correct Answer is C

Explanation

A. Decreased serum albumin levels can be an indicator of protein malnutrition, but it may not reflect overall nutritional status comprehensively. It is more specific to protein status.

B. Decreased vitamin D levels are related to a specific nutrient (vitamin D) and may indicate a deficiency in that vitamin, but it doesn't provide a broad assessment of overall nutritional status.

C. Unintentional weight loss is a key indicator of potential nutritional deficit.

Unintentional weight loss is a significant concern, especially in older adults, as it can be indicative of various underlying health issues, including malnutrition. It is a more general indicator of overall nutritional status.

D. Anorexia lasting more than 24 hours may contribute to weight loss, but it is a symptom rather than a direct measure of nutritional status. Unintentional weight loss encompasses a broader view of changes in body weight that may signal nutritional deficits.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is D

Explanation

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?

Correct Answer is C

Explanation

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?

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

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?

An older client is admitted to the hospital for treatment of pneumonia. The client has a court appointed conservator who manages her finances. The nurse understands what fact about the situation?

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.)

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?

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

The nurse plans care to prevent a dangerous thermal environment for an older adult client who lives in a northern climate of the United States. Which client assessment data does the nurse recognize that can contribute to the risk of hypothermia? (Select all that apply.)