A nurse is working a night shift and caring for several clients at risk for falls. Which of the following actions should the nurse take? (Select all that apply.)
Instruct the clients to use the call light.
Move overbed tables away from the bed.
Place a fall risk wristband on each of the clients.
Perform client checks every 4 hr.
Keep the clients' rooms dark.
Correct Answer : A,B,C,D
A. Instruct the clients to use the call light.
Encouraging clients to use the call light enables them to request assistance when needed, reducing the risk of falls if they need help to move or get out of bed.
B. Move overbed tables away from the bed.
Clearing the area around the bed, including overbed tables, reduces obstacles and potential hazards that clients might trip over or get tangled in.
C. Place a fall risk wristband on each of the clients.
Identifying clients at risk for falls by using wristbands helps alert all healthcare staff to take necessary precautions and provide appropriate assistance to prevent falls.
D. Perform client checks every 4 hr.
Regular client checks allow the nurse to monitor their condition, reposition them if necessary, assist with toileting needs, and ensure they're safe, especially during the night when falls might be more likely.
E. Keep the clients' rooms dark.
Keeping the room dimly lit during the night can help clients sleep better but should still provide enough light for safe movement. Complete darkness might increase the risk of falls if clients need to move around.
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Related Questions
Correct Answer is B
Explanation
A. Improved speech patterns:
While selegiline may contribute to overall improvement in motor function and quality of life for individuals with Parkinson's disease, it is not specifically known for targeting speech patterns.
B. Decreased tremors:
This is the correct therapeutic outcome. Selegiline is a monoamine oxidase type B (MAO-B) inhibitor that helps increase dopamine levels in the brain. Reduction of tremors is a common therapeutic effect in Parkinson's disease.
C. Increased bladder function:
Selegiline primarily affects motor symptoms in Parkinson's disease and is not directly associated with changes in bladder function.
D. Diminished drooling:
While drooling can be a symptom of Parkinson's disease, selegiline's primary focus is on motor symptoms, and its impact on drooling may be variable. Other interventions may be considered for managing drooling in Parkinson's disease.
Correct Answer is D
Explanation
A. Provide client care as assigned:
While it is essential to be flexible and adaptable, patient safety is a priority. If the nurse is not familiar with certain skills or techniques and believes it could compromise patient safety, blindly providing care may not be the best option.
B. Make a formal complaint to the nursing manager:
Making a formal complaint should not be the initial step. It is better to explore other options before escalating the situation to a higher level.
C. Request the charge nurse to modify the assignment:
This is a reasonable option. The nurse can communicate concerns to the charge nurse and request modifications to the assignment based on their skills and competency.
D. Ask another nurse to trade assignments:
This is the most immediate and practical solution. If there's another nurse available who is more familiar with the required skills, trading assignments can ensure that the patient receives appropriate care from a nurse with the necessary expertise.
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