A nurse is developing a plan of care for a client who is at risk for falls. Which of the following interventions should the nurse include?

Install a bed exit sensor pad at the foot of the client's bed.

Encourage the client to ambulate in compression stockings.

Raise all four side rails for the client at bedtime.

Place a raised toilet seat in the client's bathroom.

Answer and Explanation

The Correct Answer is D

A. Install a bed exit sensor pad at the foot of the client's bed. While a bed exit sensor pad can be useful, it is typically placed on the mattress near the client's hips or lower back, not at the foot of the bed. This placement ensures it detects movement when the client tries to get up, thereby alerting staff to provide assistance.
B. Encourage the client to ambulate in compression stockings. Compression stockings can help with circulation but do not directly address fall prevention. Additionally, they can be slippery on some surfaces, potentially increasing the risk of falls if proper footwear is not used.
C. Raise all four side rails for the client at bedtime. Raising all four side rails is considered a form of restraint and can increase the risk of injury if the client attempts to climb over them. It can also limit the client’s ability to get out of bed independently and safely.
D. Place a raised toilet seat in the client's bathroom. This intervention is appropriate for fall prevention. A raised toilet seat can help clients with mobility issues by making it easier to sit down and stand up, thereby reducing the risk of falls in the bathroom, which is a common site for falls.

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Correct Answer is B

Explanation

A. Squeeze the handles of extinguisher. This is done after aiming at the base of the fire and pulling the pin.
B. Pull out the safety pin of the extinguisher. This is the first step to unlock the extinguisher for use.
C. Sweep extinguisher from side to side at the base of fire. This is done after aiming and squeezing the handles.
D. Aim the extinguisher at the base of fire. This is the second step, after pulling the pin.

A. Keeping a record of dry nights in a daily diary B. Beginning medication therapy to inhibit urination C. Using an alarm to wake the child at the onset of urination D. Using stickers as positive reinforcement for dry nights

Correct Answer is C

Explanation

A. Keeping a record of dry nights in a daily diary: This can be helpful for tracking progress but is not the most effective intervention for treating enuresis.
B. Beginning medication therapy to inhibit urination: Medication can be used in some cases, but it is typically not the first-line treatment for enuresis.
C. Using an alarm to wake the child at the onset of urination: This is correct. Bedwetting alarms are considered the most effective intervention for treating enuresis. They condition the child to wake up or hold urine when the bladder is full.
D. Using stickers as positive reinforcement for dry nights: This can be useful as part of a behavioral approach but is not as effective as using a bedwetting alarm.

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A nurse is developing a plan of care for a client who is at risk for falls. Which of the following interventions should the nurse include?

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Naxlex Comprehensive Predictor Exams

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