The nursing staff are caring for a confused patient who is at risk for falling.
What action by the nurse would be appropriate in order to avoid restraining the patient?

Avoid assisting the patient to walk if they are restless.

Discourage the family from staying with the patient.

Move the patient to a room farther away from the nurses station.

Ask the family what movies or music the patient would enjoy and offer them.

Answer and Explanation

The Correct Answer is D

Choice A rationale:

Avoiding assisting a restless patient to walk does not address the issue of patient confusion and the risk of falling. Restless patients might need assistance, and refusing to help them walk could lead to further complications or falls.

Choice B rationale:

Discouraging the family from staying with the patient does not promote patient safety. Family members can provide additional support and supervision, reducing the risk of falls for a confused patient.

Choice C rationale:

Moving the patient farther away from the nurses' station does not address the patient's confusion or the risk of falling. It might even increase the response time in case of an emergency.

Choice D rationale:

Asking the family about the patient's preferences for movies or music and offering these activities is an appropriate way to engage the patient without resorting to restraints. Providing stimulating and enjoyable activities can help distract and calm the patient, reducing restlessness and the risk of falls.

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Correct Answer is C

Explanation

Choice A rationale:

While a patient with left arm weakness may have some mobility limitations, it does not necessarily put them at the highest risk for falling compared to the other options provided.

Choice B rationale:

Needing glasses for reading small print does not directly indicate a high risk of falling. The patient can still have good overall mobility and balance.

Choice C rationale:

A confused patient experiencing nausea due to a head injury is at the highest risk for falling. Confusion impairs judgment and decision-making abilities, increasing the likelihood of accidents. Nausea can further destabilize the patient, making them prone to falls.

Choice D rationale:

Using grab bars in the hospital bathroom indicates that the patient is aware of their limitations and is taking precautions to prevent falls. This does not suggest a higher risk compared to a confused and nauseous patient.

A. 12.7 cm. B. 12.7 cm. C. 10 cm. D. 20cm

Correct Answer is B

No explanation

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The nursing staff are caring for a confused patient who is at risk for falling.What action by the nurse would be appropriate in order to avoid restraining the patient?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Explanation

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The nursing staff are caring for a confused patient who is at risk for falling.
What action by the nurse would be appropriate in order to avoid restraining the patient?