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","D","E","F"]

Explanation

A. Stroke under the chin in a downward motion.
Explanation: Stroking under the chin in a downward motion is not considered a standard technique for managing dysphagia. It's important to focus on strategies that promote safe swallowing and prevent aspiration.

B. Keep pulse oximeter ready at all times.
Explanation: While monitoring oxygen saturation is important in certain situations, having a pulse oximeter ready at all times may not be a routine instruction for feeding a client with dysphagia. Monitoring for signs of distress and ensuring a safe feeding environment are key aspects of care.

C. Avoid rushing the client or force feeding her.
Explanation: Rushing or force-feeding a client with dysphagia can increase the risk of aspiration. It's important to allow the client to eat at their own pace and take adequate time to chew and swallow safely.

D. If facial weakness is present, place food on the impaired side of the mouth.
Explanation: Placing food on the impaired side of the mouth can help compensate for facial weakness and promote more effective chewing and swallowing.

E. Alternate solid and liquid boluses.
Explanation: Alternating solid and liquid boluses can help with the overall coordination of the swallowing process. It can also facilitate the movement of food and liquids through the digestive tract.

F. Have the client sit at 90 degrees during all of oral intake.
Explanation: Ensuring that the client sits at a 90-degree angle during oral intake helps promote an upright position that aids in swallowing and reduces the risk of aspiration.

A. Use absorbent incontinent pads B. Eat high-protein meals. C. Layer clothing, and bed clothes, D. Use a head covering E. Use your comfort level to set the thermostat

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

Explanation

A. Use absorbent incontinent pads.
Explanation: While absorbent incontinent pads are useful for managing incontinence, they do not directly contribute to preventing hypothermia. Maintaining warmth through appropriate clothing and insulation is more relevant to hypothermia prevention.

B. Eat high-protein meals.
Explanation: Consuming high-protein meals is important for maintaining energy and body heat. Protein metabolism produces heat as a byproduct, contributing to overall warmth.

C. Layer clothing and bedclothes.
Explanation: Layering helps trap warmth close to the body, providing insulation. This is an effective strategy to prevent heat loss and maintain body temperature.

D. Use a head covering.
Explanation: A significant amount of heat is lost through the head. Wearing a head covering, such as a hat or a cap, helps to minimize heat loss and maintain body temperature.

E. Use your comfort level to set the thermostat.
Explanation: Relying solely on personal comfort to set the thermostat may not provide adequate protection against hypothermia. It is important to keep indoor temperatures at a level that ensures warmth and minimizes the risk of cold exposure, especially for elderly individuals who may be more susceptible to temperature extremes.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client care assistant has been assigned to feed your female client with dysphagia. Which of the following instructions would you give the assistant? (Select all that apply.)

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

Explanation

Hypothermia is a medical emergency defined as a core temperature less than 95°F. Which of the following tips to prevent hypothermia should you tell your elderly client? (Select all that apply.)

Correct Answer is ["B","C","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?

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.)

Which of the following statements are true about Medicare-part 8 supplemental insurance? (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 adult who is on bed rest after surgery is prescribed morphine for pain. Which of the following is the nurse's priority for preventive care?

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:

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?