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.

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Free Nursing Study Resources

Correct Answer is A

Explanation

A. Transportation can be a critical factor in nutritional insufficiency in older adults.
Explanation: Limited access to transportation can be a barrier for older adults in obtaining nutritious food. This can lead to challenges in grocery shopping and accessing fresh, healthy food options. Lack of transportation may contribute to nutritional insufficiency in older individuals.

B. Soul food is a concern primarily for the African-American culture.
Explanation: This statement is not accurate. Dietary concerns and considerations, including those related to health, are not exclusive to any particular culture. Soul food, like any cuisine, can be enjoyed in moderation, but it's important to focus on a balanced and nutritious diet.

C. No government programs promote congregate dining among older adults.
Explanation: This statement is not true. There are government programs, such as the Older Americans Act Nutrition Program, that support congregate dining among older adults. These programs aim to provide nutritious meals to older individuals and foster social interactions by offering group dining opportunities.

D. The older person should be encouraged to practice strict controls on cholesterol intake to ensure protection against heart disease.
Explanation: While monitoring cholesterol intake is important for heart health, the term "strict controls" might not be universally applicable. Recommendations for cholesterol intake can vary based on an individual's overall health status, medical history, and specific dietary needs. It's advisable to consult with a healthcare professional for personalized advice on cholesterol management for older adults.

A. Assist with obtaining informed consent from the client. B. Refer to the client's advance directive for a name. C. Determine the client's inability to make reasonable decisions. D. Use the oral trail-making test to measure cognitive function.

Correct Answer is C

Explanation

A. Assist with obtaining informed consent from the client.
Explanation: Informed consent is a critical aspect of healthcare procedures, but it requires the patient to have the capacity to understand and make decisions. In this scenario, the client is intubated and on mechanical ventilation, which might compromise their ability to communicate effectively. If the client lacks capacity, obtaining consent from the durable power of attorney (POA) is more appropriate.

B. Refer to the client's advance directive for a name.
Explanation: Advance directives, including the durable POA, provide guidance on a person's wishes for healthcare decisions when they are unable to communicate. However, the advance directive may not always specify a particular person's name for decisions related to specific medical interventions. The key consideration in this situation is to determine the current decision-making capacity and involve the appropriate decision-maker if needed.

C. Determine the client's inability to make reasonable decisions.
Explanation: This is the correct answer. In this scenario, the nurse should assess the client's capacity to make decisions. If the client lacks capacity, the durable POA can be activated to make healthcare decisions on behalf of the client. Capacity involves the ability to understand relevant information, appreciate the consequences of decisions, and communicate a choice.

D. Use the oral trail-making test to measure cognitive function.
Explanation: The oral trail-making test is a cognitive screening tool, but it may not be suitable in this critical care scenario with an intubated and mechanically ventilated patient. Moreover, the primary concern in this situation is determining the capacity to make healthcare decisions, which requires a more comprehensive evaluation than a specific cognitive function test. The focus should be on decision-making capacity rather than a cognitive assessment.

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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

Which of the following is a true statement about nutrition for older adults?

Correct Answer is A

Explanation

A health care provider asks the nurse about an older adult client's durable power of attorney (POA) because consent is needed for a medically necessary invasive procedure. The client has end-stage disease, is intubated, and is on mechanical ventilation. Which steps should the nurse implement?

Correct Answer is C

Explanation

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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?