An unlicensed assistive personnel (UAP) is caring for a client who is confused and at risk for falls. Which action should the nurse instruct the UAP to implement?

Encourage relaxation through massage.

Lowering the height of the bed.

Set up a pressure-sensitive alarm on bed and chair.

Placing the client in a safety vest.

Answer and Explanation

The Correct Answer is C

Choice A reason: Encouraging relaxation through massage may reduce agitation but does not directly prevent falls. Confusion increases fall risk, requiring environmental safety measures. Massage lacks evidence as a primary fall prevention strategy, making it less effective than alarms or bed adjustments for a confused, high-risk client.

Choice B reason: Lowering the bed height reduces fall injury risk but is less proactive than a pressure-sensitive alarm. Alarms alert staff to movement, preventing falls before they occur. Bed height adjustment is a secondary measure, as it mitigates injury rather than addressing the immediate risk of unsupervised movement.

Choice C reason: Setting up a pressure-sensitive alarm on the bed and chair alerts staff when the confused client attempts to move, preventing falls. This proactive measure addresses the high fall risk in real-time, aligning with evidence-based safety protocols. Alarms are critical for confused clients, ensuring timely intervention to maintain safety.

Choice D reason: Placing the client in a safety vest is a restraint, which is a last resort due to ethical and safety concerns. Restraints can increase agitation and injury risk in confused clients. Pressure-sensitive alarms are less invasive, promoting safety without compromising autonomy, making them the preferred fall prevention strategy.

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Correct Answer is C

Explanation

Choice A reason: Newly pregnant women benefit from informational teaching about prenatal care, but role-playing is less effective for this group. Their focus is on factual knowledge, like nutrition or labor preparation. Role-playing is better suited for behavioral change, making it less impactful for this group’s educational needs.

Choice B reason: Older adults preparing for retirement need guidance on financial or lifestyle adjustments, where role-playing is less effective. Didactic or discussion-based teaching better addresses their needs. Role-playing suits behavioral skill-building, which is not the primary focus for this group, making it a less beneficial method.

Choice C reason: Adolescents learning to abstain from drugs benefit from role-playing, as it builds skills to resist peer pressure and practice refusal strategies. This interactive method engages teens, reinforcing behavioral change through simulated scenarios. Evidence supports role-playing for adolescent substance abuse prevention, making it highly effective for this group’s needs.

Choice D reason: Men admitting a drinking problem benefit from support groups or counseling, but role-playing is less tailored to their needs. Their focus is on emotional processing and coping strategies. Role-playing is more effective for skill-building in social contexts, like drug refusal, than for addressing established addiction.

A. Notify the healthcare provider (HCP). B. Document the event in the electronic health record (EHR). C. Inform the nurse on the next shift. D. Complete an incident report.

Correct Answer is A

Explanation

Choice A reason: Notifying the HCP immediately ensures prompt evaluation of the medication error’s impact and any needed interventions. Administering an unprescribed antibiotic risks adverse reactions or ineffective treatment. Prompt notification supports patient safety, aligns with error management protocols, and allows the HCP to adjust the care plan accordingly.

Choice B reason: Documenting in the EHR is critical but secondary to notifying the HCP. Immediate notification allows the provider to assess and mitigate harm from the unprescribed antibiotic. Documentation follows to record the error and actions taken, but delaying HCP contact risks prolonged exposure to potential adverse effects.

Choice C reason: Informing the next shift’s nurse ensures continuity but is not the priority. Notifying the HCP first addresses the immediate clinical implications of the unprescribed antibiotic. Shift reports are secondary, as the error requires prompt provider intervention to evaluate the client’s condition and prevent harm from the medication mistake.

Choice D reason: Completing an incident report is necessary for quality improvement but not the first step. Notifying the HCP ensures immediate clinical action to address the unprescribed antibiotic’s effects. Incident reports follow to analyze system issues, but patient safety requires provider notification first to manage potential adverse outcomes.

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An unlicensed assistive personnel (UAP) is caring for a client who is confused and at risk for falls. Which action should the nurse instruct the UAP to implement?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse wants to use role-playing as a teaching technique. Which group is most likely to benefit from this teaching method?

Correct Answer is C

Explanation

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Correct Answer is A

Explanation

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