A nurse at a long-term care facility is planning a fall prevention program for the residents. Which of the following interventions should the nurse include?
Keep the four side rails up on beds at night.
Institute rounds every 2 hr during the day to offer toileting
Accompany residents older than 85 years of age during ambulation
Apply vest restraints on residents who are confused.
Apply vest restraints on residents who are confused.
The Correct Answer is B
A. Keeping all four side rails up on beds can increase the risk of entrapment or injury and isn't recommended as a fall prevention strategy.
B. Instituting regular rounds during the day to offer toileting helps prevent falls related to residents attempting to get to the bathroom independently.
C. Accompanying older residents during ambulation is helpful but might not be feasible at all times and for all residents.
D. Using vest restraints can lead to physical and psychological complications and is not recommended due to ethical and safety concerns.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Calling the pharmacy for a prescription for the client's partner doesn't necessarily violate client confidentiality as it pertains to the partner's care.
B. Providing a copy of the client's medical record to a third party, the transporting paramedic, breaches confidentiality as it exposes the client's private health information to someone not
involved in direct care.
C. Reporting a client's disposition to the referring provider is part of normal care coordination and doesn't typically violate confidentiality.
D. Informing housekeeping staff about a client's location in a specific unit doesn't divulge confidential health information.
Correct Answer is D
Explanation
A. A generalized rash over the trunk might indicate various conditions but might not be an immediate concern in the context of meningitis.
B. An increased temperature is an expected finding in meningitis and should be
monitored but might not necessitate immediate reporting unless exceptionally high or coupled with other concerning symptoms.
C. Photophobia, or sensitivity to light, is a common symptom in meningitis but alone might not necessitate immediate reporting if the client's other symptoms are stable.
D. Decreased level of consciousness can indicate neurological deterioration and requires immediate attention as it could signal worsening of the client's condition.
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