Which interventions can the practical nurse (PN) implement to help minimize the risk of falls in a client who has been identified as having a high fall risk? Select all that apply.

Ensure all four side rails of the bed are in upright position.

Perform hourly bedside rounds.

Keep bed in lowest position.

Place client in a room close to the nurses' station.

Use chair and bed alarms.

Answer and Explanation

Correct Answer : B,C,D,E

Rationale:
A. This option is incorrect because raising all four side rails is considered a form of restraint and is not recommended for fall prevention. Clients may attempt to climb over the rails, which significantly increases the risk of serious injury. Best practice is to use the least restrictive measures while maintaining safety.

B. This option is correct because hourly bedside rounds allow the PN to anticipate and address client needs such as pain, toileting, repositioning, and comfort. Proactively meeting these needs reduces the likelihood that the client will attempt to get out of bed unassisted, thereby lowering fall risk.

C. This option is correct because keeping the bed in the lowest position minimizes the height from which a client could fall. It also makes it easier and safer for the client to transfer in and out of bed with assistance.

D. This option is correct because assigning the client to a room close to the nurses’ station increases visibility and allows for faster response if the client becomes unsteady or attempts to ambulate without help. Close observation is especially important for clients with cognitive impairment or frequent toileting needs.

E. This option is correct because chair and bed alarms provide an early warning when a high-risk client attempts to stand or move independently. These alarms enable staff to intervene promptly, preventing falls while still promoting mobility with supervision.

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Correct Answer is C

Explanation

Rationale:
A. Degree of interference with sexual relationships is incorrect because while this may be relevant later, it is not the primary concern when assessing the impact of urinary incontinence on daily life.

B. Number of urinary tract infections in the last 12 months is incorrect as this is more related to risk factors and complications, not the current functional impact of incontinence.

C. Information on how the problem impacts lifestyle is correct because urinary incontinence affects quality of life, social interactions, and activities of daily living. Understanding the lifestyle impact helps the PN plan individualized interventions, provide education, and refer to appropriate support or treatment options.

D. Knowledge of companies that deliver incontinence products is incorrect because providing resource information is secondary to assessing the actual impact of the problem on the client’s life.

A. Apply consequential punishment. B. Encourage self-determination. C. Reward positive behavior. D. Implement negative reinforcement.

Correct Answer is B

Explanation

Rationale:
A. This option is incorrect because using punishment is not an effective teaching strategy. Punitive approaches can create fear or resistance, reduce motivation, and do not promote long-term behavioral change or self-management.

B. This option is correct because encouraging self-determination empowers the client to take an active role in their care, make informed decisions, and set personal goals. This client-centered approach enhances motivation, engagement, and retention of teaching, leading to better adherence to discharge instructions.

C. This option is incorrect because while rewarding positive behavior can be supportive, it is more behaviorist and externally motivated. It may encourage compliance temporarily but does not promote internal motivation or long-term self-management as effectively as self-determination.

D. This option is incorrect because negative reinforcement involves removing an unpleasant stimulus to encourage behavior. While it can influence behavior, it is not an ideal approach for client teaching and goal setting, as it does not foster intrinsic motivation or autonomy.

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Which interventions can the practical nurse (PN) implement to help minimize the risk of falls in a client who has been identified as having a high fall risk? Select all that apply.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client arrives to the clinic for treatment of a cough. The client reports sometimes urinating accidentally while coughing and states, "It is a normal part of aging I suppose." Which assessment should the practical nurse (PN) make?

Correct Answer is C

Explanation

The practical nurse (PN) is reinforcing discharge teaching with a client. Which teaching approach should the PN use to facilitate learning and to reach client- centric goals?

Correct Answer is B

Explanation

The practical nurse (PN) observes a coworker crying and expresses concern. The coworker confides to having personal issues and feeling emotional and overwhelmed. The PN recommends suggestions for support systems that may be helpful. Which principle is the PN displaying?

The practical nurse (PN) observes a female client grimacing and holding her neck. The PN determines that the client is in pain. To validate this assessment with subjective data, which action should the PN implement?

When evaluating a client's plan of care (POC), the registered nurse (RN) determines that several of the expected outcomes were not met. To assist the RN, which action should the practical nurse (PN) take?

A client arrives to the clinic and describes concerns to the practical nurse (PN) about having mood swings, insomnia, and a lack of focus. Which information should the PN obtain first?

When completing a focused skin assessment of a client, the practical nurse (PN) notices erythema on the client's right hip. Which should the PN include in the client's plan of care?

When a client with diarrhea becomes diaphoretic, the practical nurse (PN) measures the client's vital signs and finds that the client is febrile with a rapid pulse and respiratory rate and a slightly decreased blood pressure. Which additional assessment finding is this client likely to exhibit?

A client is in a left side lying position while the practical nurse (PN) is making the occupied bed. The PN observes that the client is experiencing orthopnea. Which action should the PN implement?