A patient has been admitted and placed on fall precautions. The nurse explains to the patient that interventions for the precautions include:
Encouraging visitors in the early evening
Placing all four side rails in the 'up' position
Checking on the patient once a shift
Placing a 'high risk for falls' armband on the patient
The Correct Answer is D
A. Encouraging visitors may not directly relate to fall prevention strategies.
B. While side rails can be used, having all four up may not be appropriate or necessary; this can restrict mobility.
C. Checking on the patient more frequently than once a shift is essential for preventing falls.
D. Placing a 'high risk for falls' armband alerts staff to the patient’s risk and is a standard precautionary
measure.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. The pre-interaction phase involves planning and preparing before meeting the patient.
B. The orientation phase includes establishing rapport and setting goals, but not indicating the end of visits.
C. The working phase focuses on implementing care and supporting patient needs.
D. The termination phase involves preparing the patient for the conclusion of care, as indicated by the
nurse’s statement.
Correct Answer is A
Explanation
A. Redefining professional boundaries is necessary to maintain an appropriate nurse-patient relationship.
B. Giving out personal contact information is unprofessional and can lead to boundary issues.
C. Providing false information is unethical and could damage trust.
D. While transferring care may be appropriate in some situations, addressing the boundary issue first is critical.
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