A nurse at a long-term facility is planning a fall prevention program for the residents. Which of the following interventions should the nurse include?

Institute rounds every 2 hr. during the day to offer toileting.

Keep four side rails up on the beds at night

Apply vest restraints on the residents who are confused

Accompany residents older than 85 years of age during ambulation

Answer and Explanation

The Correct Answer is A

a.   Instituting rounds every 2 hours during the day to offer toileting can help prevent falls by addressing residents' toileting needs and reducing the risk of falls associated with attempting to ambulate to the bathroom independently.
b.   Keeping four side rails up on the beds at night may increase the risk of entrapment and should be avoided as a fall prevention strategy.
c.   Applying restraints, such as vest restraints, is not recommended as a fall prevention measure and may increase agitation and risk of injury.
d.   While providing assistance during ambulation is important, it is not necessary to accompany all residents older than 85 years of age. Ambulation assistance should be provided based on individual assessment of mobility and fall risk.

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Correct Answer is D

Explanation

A. Collaborating involves working together with all parties to find a mutually beneficial solution. This approach values input from others and seeks consensus, which is not demonstrated in the scenario.

B. Cooperating typically refers to acknowledging and accommodating others' concerns while trying to maintain relationships. The nurse manager’s approach does not reflect this strategy, as she is disregarding opposing feelings.

C. Compromising seeks a middle ground where both parties can give and take to reach an agreement. The nurse manager's unilateral decision-making does not align with compromising.

D. Competing is characterized by an assertive and uncooperative stance, where one party seeks to impose their preferred solution without regard for others’ input or feelings. The nurse manager’s decision to implement changes despite opposition exemplifies this strategy.

A. Assault B. Libel C. Battery D. False imprisonment

Correct Answer is C

Explanation

a. Assault: Assault is the threat of harm to another individual, such as threatening to administer the injection against the client's will. However, since the nurse actually administers the injection, it does not constitute assault.
b. Libel: Libel refers to a false statement that is written and published, which is not relevant in this scenario.
c. Battery: Battery involves the unauthorized or harmful physical contact with another individual, such as administering the injection without the client's consent.
d. False imprisonment: False imprisonment occurs when an individual is unlawfully restrained or confined. While the client's movement may be restricted by administering the injection, the primary issue here is the unauthorized physical contact, making battery the more appropriate choice.

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A nurse at a long-term facility is planning a fall prevention program for the residents. Which of the following interventions should the nurse include?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is D

Explanation

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Correct Answer is C

Explanation

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