The health care provider has not ordered the use of a restraint for an alert patient at high risk for falling. The nurse should implement which side rail use?

Four -length rails

One-length rail

Two full-length rails

No side rails

Answer and Explanation

The Correct Answer is B

A. Four-length rails.

Explanation: Four-length rails fully enclose the bed and can be considered a more restrictive measure. They may be used when a restraint order is in place, but for an alert patient without such an order, less restrictive alternatives are preferred.

B. One-length rail.

Explanation: Using one-length rails can be a less restrictive alternative when a patient is at high risk for falling. The use of one side rail allows for some protection against falls without fully restraining the patient. This approach helps maintain the patient's mobility and autonomy while still providing a safety measure.

C. Two full-length rails.

Explanation: While using two full-length rails is less restrictive than four-length rails, it is still more restrictive than using only one side rail. The goal is to balance fall prevention with the patient's autonomy.

D. No side rails.

Explanation: Using no side rails may not provide adequate protection for an alert patient at high risk for falling. While avoiding restraints is essential, implementing at least one side rail is a reasonable compromise to enhance safety without fully restricting the patient's movement.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is ["A","B","C","D","F"]

Explanation

A. Right to visitation from others except legal advisors, who must obtain permission from the nursing facility before visiting the older adult

Explanation: The right to receive visitors is generally protected, with some reasonable restrictions, to ensure the safety and well-being of residents.

B. Right to be free from restraints

Explanation: Residents have the right to be free from unnecessary physical or chemical restraints, as outlined in their Bill of Rights. Restraints should only be used when necessary for the safety of the resident or others, and their use should be minimized.

C. Right to have a say in their care and treatment

Explanation: Residents have the right to actively participate in decisions about their care and treatment. This includes being informed about their options and having the opportunity to express their preferences.

D. Right to voice grievances

Explanation: Residents have the right to voice complaints or grievances without fear of retaliation. The nursing home must have a system in place to address and resolve residents' concerns.

E. "Right to information about their health but not about their medications" is not accurate. Residents have the right to be informed about all aspects of their health, including information about medications prescribed to them. Information about medications is an important component of informed consent and shared decision-making.

F. Right to be free from abuse

Explanation: Residents have the right to be free from any form of abuse, whether it is physical, verbal, psychological, or any other form. Nursing homes must take measures to prevent and address any instances of abuse.

A. Use of resistance bands B. Stretching C. Tat chi D. Yoga E. ROM activities

Correct Answer is ["C","D","E"]

Explanation

A. Use of resistance bands
Explanation: Resistance band exercises can improve strength and flexibility, but they may not specifically address balance as directly as Tai Chi or certain yoga poses.

B. Stretching
Explanation: Stretching exercises contribute to flexibility and can be part of a well-rounded exercise routine. While they can be beneficial, other exercises like Tai Chi and yoga may have a more specific focus on balance improvement.

C. Tai Chi
Explanation: Tai Chi is a low-impact exercise that emphasizes slow, controlled movements, weight shifting, and mindfulness. It has been shown to improve balance and reduce the risk of falls, making it suitable for individuals at high risk.

D. Yoga
Explanation: Yoga incorporates balance, flexibility, and strength exercises. Certain yoga poses can help improve balance and stability, making it beneficial for individuals at risk for falls.

E. Range of Motion (ROM) activities
Explanation: Range of motion activities helps maintain joint flexibility and can contribute to improved balance. Encouraging the client to perform gentle range of motion exercises can be beneficial.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

The health care provider has not ordered the use of a restraint for an alert patient at high risk for falling. The nurse should implement which side rail use?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The Bill of Rights for long-term residents was created to protect the rights of the residents in nursing homes. Which of the following examples protect these rights? (Select all that apply.)

Correct Answer is ["A","B","C","D","F"]

Explanation

The nurse should encourage which of the following exercise(s) to assist with balance for a client who is at high risk for falls? (Select all that apply.

Correct Answer is ["C","D","E"]

Explanation

A client care assistant has been assigned to feed your female client with dysphagia. Which of the following instructions would you give the assistant? (Select all that apply.)

An older client is admitted to the hospital for treatment of pneumonia. The client has a court appointed conservator who manages her finances. The nurse understands what fact about the situation?

A 79-year-old client resides independently in the community. The visiting home health nurse finds that despite it being 90°F outside, the windows are closed and the client is wearing a sweater. The nurse initially recognizes that this behavior may be related to what?

As a nurse caring for a cognitively impaired older adult client, you need to observe for which of the following? (Select all that apply.)

A nurse is assessing an older adult's nutritional status. The nurse understands that which of the following is the most important indicator for a potential nutritional deficit?

Which of the following statements is true about conservators?