What interventions should the nurse include in the plan of care for a patient on fall precautions? Select all that apply.

Restrain the patient with a chemical sedative.

Encourage the patient to use grab bars located near toilets and showers.

Place the call light within the patient's reach.

Conduct rounds every four hours.

Apply brakes on wheelchairs and bed.

Answer and Explanation

Correct Answer : B,C,E

Choice A rationale:

Restrain the patient with a chemical sedative. Rationale: Restraints, especially chemical sedatives, should be avoided whenever possible due to the risk of complications and patient distress. Restraints can lead to decreased mobility, increased agitation, and other adverse effects. They should only be used as a last resort and with appropriate justification, such as ensuring patient or staff safety in emergency situations.

Choice B rationale:

Encourage the patient to use grab bars located near toilets and showers. Rationale: Installing grab bars in bathrooms helps prevent falls by providing support and stability for patients, especially those with mobility issues. Encouraging their use promotes patient independence and safety while performing essential activities of daily living.

Choice C rationale:

Place the call light within the patient's reach. Rationale: Placing the call light within the patient's reach ensures that the patient can easily summon assistance when needed. Prompt response to patient requests can prevent accidents and falls by addressing the patient's needs in a timely manner.

Choice D rationale:

Conduct rounds every four hours. Rationale: Conducting regular rounds allows healthcare providers to assess the patient's condition, address their needs, and identify potential fall risks. However, the specific frequency of rounds may vary based on the patient's condition and the healthcare facility's policies. Some patients may require more frequent monitoring, especially if they are at a higher risk of falling.

Choice E rationale:

Apply brakes on wheelchairs and beds. Rationale: Applying brakes on wheelchairs and beds prevents unintended movement, enhancing patient safety and reducing the risk of falls. It ensures that the patient's mobility aids remain stationary, providing stability when the patient is transferring or repositioning.

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Correct Answer is B

Explanation

Choice A rationale:

Statements provided by the patient's family are not a reliable defense against nursing negligence. While family statements can offer context, they may not always be accurate or objective. Legal defenses require concrete evidence and accurate documentation.

Choice B rationale:

Accurate documentation by the nurse is the best defense against allegations of nursing negligence. Thorough and precise documentation provides a clear account of the patient's condition, the care provided, and the patient's response. Proper documentation is essential for legal and ethical reasons and serves as a valuable defense in case of legal disputes.

Choice C rationale:

Testimony of other nurses may support the case but may not be as reliable as accurate documentation. Nurse testimony can be subjective and may vary, making it less robust as a defense compared to comprehensive and detailed documentation.

Choice D rationale:

Inclusion of expert witnesses can be helpful, but their testimony is most effective when combined with accurate documentation. Expert witnesses can provide specialized knowledge and opinions, but their credibility is enhanced when supported by thorough and precise nursing documentation.

A. Avoid assisting the patient to walk if they are restless. B. Discourage the family from staying with the patient. C. Move the patient to a room farther away from the nurses station. D. Ask the family what movies or music the patient would enjoy and offer them.

Correct Answer is D

Explanation

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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What interventions should the nurse include in the plan of care for a patient on fall precautions? Select all that apply.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The student nurse is reviewing topics related to laws that apply to nursing care.The student nurse is correct in stating which one is the nurse's best defense if a patient alleges nursing negligence?

Correct Answer is B

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Correct Answer is D

Explanation

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