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

Answer and Explanation

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.

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Correct Answer is B

Explanation

A. Venting can be therapeutic, but it doesn’t directly promote self-awareness.
B. Allowing open exploration of thoughts and feelings helps the patient reflect and gain insight into their emotions and behaviors.
C. Physically punching a pillow does not facilitate self-awareness and may encourage aggressive behavior.
D. Writing complaint letters might help express frustration but does not foster self-awareness.

A. Defer the bath until evening and pass on the information to the next shift B. Tell the patient that she must bathe because this is the "normal" routine C. Explain to the patient the importance of maintaining morning hygiene practices D. Cancel hygiene for the day and attempt again in the morning

Correct Answer is A

Explanation

A. Accommodating the patient's preference fosters a positive therapeutic relationship and respects her autonomy.
B. Insisting on a "normal" routine may lead to resistance and decreased trust.
C. Education about hygiene is valuable, but should be tailored to patient preferences.
D. Skipping hygiene entirely is not appropriate; it’s better to find a compromise.

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A patient has been admitted and placed on fall precautions. The nurse explains to the patient that interventions for the precautions include:

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse can assist the patient in becoming more self-aware by using which technique?

Correct Answer is B

Explanation

The nurse is caring for a patient who refuses "AM care". When asked why, the patient tells the nurse that she always bathes in the evening. The nurse should:

Correct Answer is A

Explanation

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