When developing a care plan for a patient at risk of falls, which intervention is most important to include?
Keeping the bed in the lowest position
Encouraging the patient to walk alone for exercise
Placing a sign on the door alerting visitors
Assigning the patient to a room near the nurses station
The Correct Answer is A
Introduction:
Fall prevention protocols involve evidence-based clinical interventions to maintain patient safety stability. These measures are designed to minimize the potential for injury by optimizing the environment and enhancing the nurse's ability to monitor high-risk patients who demonstrate impaired balance, confusion, or weakness during their daily activities.
A. Lowest bed position is a fundamental safety measure that significantly reduces the distance a patient falls if they attempt to exit the bed unassisted. This simple environmental modification is universally recognized as a primary intervention to decrease the severity of potential injuries for all patients identified as high risk.
B. Encouraging independent walking for a patient at risk of falls is counterproductive and dangerous. Patients with balance deficits require supervision or assistance during ambulation to prevent accidents; therefore, an intervention that promotes unassisted movement would directly increase the risk of a fall and subsequent physical harm.
C. Placing a sign on the door may help alert staff to the patient's risk status, but it does not provide an active physical barrier or preventative measure to stop a fall. It is a communication tool, not a functional intervention, and therefore lacks the impact of direct physical safety measures.
D. While assigning a patient to a room near the nurses' station increases staff visibility and responsiveness, it is often not feasible due to bed availability. Therefore, it is not as universally reliable or as immediate as maintaining a low bed height, which can be implemented in any patient room.
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Related Questions
Correct Answer is A
Explanation
Introduction:
Legislative nursing regulation provides the legal framework defining the boundaries of professional practice and ensuring public safety. These statutes govern licensure, scope of practice, and professional conduct, ensuring that practitioners meet established standards of competence and adhere to regulations that protect the health of the population.
A. Defining the scope of nursing practice and protecting the public is the foundational legal mandate of the Nurse Practice Act. It grants the authority for nursing boards to regulate the profession, establish standards for licensure, and implement disciplinary actions to ensure that only qualified nurses provide safe patient care.
B. Establishing hospital internal policies is an administrative function performed by healthcare organizations, not a state-level regulatory act. While hospital policies must align with the laws set forth in the Nurse Practice Act, the act itself does not dictate the specific daily operational procedures of an individual facility.
C. Determining the salary ranges for nurses is a matter of economic compensation managed by labor market dynamics, hospital administration, and collective bargaining agreements. The Nurse Practice Act focuses exclusively on the legalities of the profession, professional standards, and public safety, not the financial remuneration of nursing staff.
D. Managing the daily administrative schedules of nursing units is an operational responsibility of nursing leadership and management within a facility. The Nurse Practice Act is a state law that regulates the practice of the profession itself, rather than dictating the internal scheduling or management workflow of specific units.
Correct Answer is D
Explanation
Introduction:
Comprehensive health history gathering requires accurate quantification of lifestyle behaviors using objective clinical inquiry. Nurses must focus on gathering measurable data, such as duration and intensity of tobacco use, to accurately assess the patient’s risk for chronic diseases, such as cardiovascular and respiratory conditions, without using judgmental language.
A. Asking how often the patient smokes during the day is redundant after the patient has already clarified they smoke half a pack per day. This question does not advance the data collection process and fails to gather the necessary longitudinal information required for an accurate clinical risk assessment.
B. Stating that the habit is very bad for the patient's health is a judgmental, non-therapeutic response. Such a comment may make the patient feel shamed or defensive, which can jeopardize the therapeutic relationship and decrease the patient's willingness to be honest about other important health behaviors in the future.
C. While smoking cessation counseling is an important long-term goal, it is not the most appropriate initial response when still collecting the baseline health history. The priority at this stage is to gather specific data about the duration and severity of the smoking habit to calculate the patient's pack-year history.
D. Quantifying smoking duration is the most appropriate follow-up question. Determining how many years the patient has smoked, in combination with the number of cigarettes per day, allows the nurse to calculate the patient's pack-year history, which is a vital clinical metric for assessing the patient's risk for tobacco-related pathologies.
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