After assessing the older client in his bed, the nurse determines that he is at high risk for falls. The nurse leaves the room to get a fall risk sign and returns to find him on the floor pleading for help. Which of the following was the most important intervention the nurse should have implemented to prevent this event?
Provide a urinal and drinking water.
Call for someone to bring the sign.
Instruct the client to use call bell for help.
Ensure he can reach his personal items
The Correct Answer is C
A. Provide a urinal and drinking water.
Explanation: While providing a urinal and drinking water is important for the client's comfort and hydration, it may not directly address the risk of falls in this situation.
B. Call for someone to bring the sign.
Explanation: Bringing a fall risk sign is a secondary measure and not as immediate as instructing the client to use the call bell. The priority is to ensure the client's safety by addressing the need for assistance promptly.
C. Instruct the client to use the call bell for help.
Explanation: Instructing the client to use the call bell for help is a crucial intervention to ensure that the client can request assistance when needed. Promptly responding to the call bell allows healthcare providers to assist the client with activities such as getting out of bed, using the bathroom, or reaching personal items without the risk of falls. Educating and encouraging clients to use the call bell empowers them to seek assistance and promotes their safety.
D. Ensure he can reach his personal items.
Explanation: Ensuring the client can reach personal items is part of providing a comfortable environment but may not prevent falls. The critical factor in fall prevention is promoting communication and the ability to request assistance in a timely manner.
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Related Questions
Correct Answer is B
Explanation
A. Encouraging the client to use a cane when ambulating is a positive preventive measure, promoting stability and support during walking.
B. Keeping the side rails up on the client's bed at night can be concerning.
While it might seem like a safety measure, using side rails can lead to entrapment or falls, especially for frail older adults. Side rails can create a false sense of security, and if the client tries to climb over them or gets caught between the rails, it can result in injury.
C. Keeping several low wattage night lights on in the evening is a good preventive measure, as it helps improve visibility and reduces the risk of falls during nighttime activities.
D. Installing wooden railings on the stairway to the bathroom is a positive preventive measure, enhancing stability and support during stair navigation.
Correct Answer is A
Explanation
A. This response provides the family member with accurate information about the limited effectiveness of drugs in improving appetite and weight gain, along with the potential for serious side effects. It promotes informed decision-making.
B. Stating that there are no drugs that impact appetite or weight gain is not entirely accurate. Some drugs may have an impact, but the effectiveness varies, and they often come with potential side effects.
C. Blanket's statements that these drugs are not permitted in long-term care facilities are not accurate. The use of medications should be based on individual assessment and treatment plans.
D. Saying "Yes, there are some very effective drugs out there. Your mother should be on one of them" is not an appropriate response. It oversimplifies the situation and may not reflect the individualized approach needed in assessing and addressing nutritional concerns.
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