A nurse is caring for a terminally ill patient during the 2300 to 0700 shift.
The patient says, "I just can't go to sleep.
I keep thinking about what my family will do when I am gone.”. What response by the nurse would be most appropriate?

Choice A rationale:

Avoiding assisting a restless patient to walk does not address the issue of patient confusion and the risk of falling. Restless patients might need assistance, and refusing to help them walk could lead to further complications or falls.

Choice B rationale:

Discouraging the family from staying with the patient does not promote patient safety. Family members can provide additional support and supervision, reducing the risk of falls for a confused patient.

Choice C rationale:

Moving the patient farther away from the nurses' station does not address the patient's confusion or the risk of falling. It might even increase the response time in case of an emergency.

Choice D rationale:

Asking the family about the patient's preferences for movies or music and offering these activities is an appropriate way to engage the patient without resorting to restraints. Providing stimulating and enjoyable activities can help distract and calm the patient, reducing restlessness and the risk of falls.

Choice A rationale:

Moving the patient to the side of the bed is the first nursing action that should be implemented when assisting the patient to a lateral position for placement of a bedpan. This step ensures proper body mechanics and patient safety during the transfer. The nurse should assist the patient to the edge of the bed, farthest from them, and then help the patient turn onto their side, facing away from the nurse. This position facilitates the placement of the bedpan and maintains the patient's dignity and comfort.

Choice B rationale:

Placing the patient's arm over the chest is a subsequent step after moving the patient to the side of the bed. After the patient is in the lateral position, the nurse should assist in placing the uppermost arm comfortably over the chest to maintain balance and stability during the bedpan placement.

Choice C rationale:

Raising the bed to a proper working height is essential for the nurse's ergonomic safety and comfort during the procedure. However, it is not the first step in assisting the patient to a lateral position. The bed should be at a height that allows the nurse to work comfortably without straining their back, but this step comes after the patient has been safely positioned on their side.

Choice D rationale:

Turning the patient using the draw sheet is another appropriate technique for repositioning patients, especially when they are unable to assist with the movement. However, in this scenario, the nurse needs to assist the patient to a lateral position for the bedpan placement, which involves different techniques. Using a draw sheet might be necessary in other situations, such as when turning a bedridden patient in bed, but it is not the first action for placing a bedpan.