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."
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
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. It provides monetary benefits to American citizens and legal residents to prevent their dependency on their families.
Explanation: Medicaid primarily provides health coverage rather than direct monetary benefits. Its focus is on ensuring access to medical care for those in need.
B. It provides a minimum level of economic support.
Explanation: While Medicaid may indirectly support individuals by covering medical expenses, its primary purpose is to provide health insurance coverage, not economic support in a general sense.
C. It is designed to help the states defray the expenses for the poor.
Explanation: This option describes the collaborative nature of Medicaid, where both federal and state governments contribute to funding. However, the primary goal is to provide health coverage to eligible individuals rather than defraying general expenses for the poor.
D. It is meant to provide insurance coverage for medical care to the older adult and disabled populations, regardless of their financial situations.
Explanation: Medicaid is a joint federal and state program that provides health coverage for certain individuals and families with low incomes, including older adults and people with disabilities. It is designed to assist individuals who may not have the financial means to afford necessary medical care. Medicaid covers a broad range of medical services, and eligibility is determined based on income, household size, and other factors.
Correct Answer is ["A","B","C","D","E"]
Explanation
A. Use cool or tepid water.
Explanation: Using cool or tepid water for activities like sponge baths or cool compresses can help lower body temperature and provide relief from heat.
B. Avoid alcohol.
Explanation: Alcohol can contribute to dehydration. Advising the client to avoid alcohol helps maintain proper hydration levels, which is crucial in preventing hyperthermia.
C. Minimize exertion.
Explanation: Excessive physical exertion in high temperatures can lead to overheating. Advising the client to minimize physical activity during peak heat hours can help prevent hyperthermia.
D. Wear cool clothing such as silk or polyester.
Explanation: Light and breathable fabrics like silk or polyester can assist in keeping the body cool by allowing better air circulation. This helps prevent overheating.
E. Drink plenty of fluids.
Explanation: Staying well-hydrated is essential in preventing hyperthermia. Encouraging the client to drink plenty of fluids helps maintain hydration and regulate body temperature.
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