Which of the following interventions is most appropriate for a patient that gets 30 points on the Morse Fall Scale? (Select All that Apply.)
Allowing the patient to ambulate independently
Administering a sedative to keep the patient calm
Placing the patient in restraints
Implementing a fall prevention protocol
Educating the patient on using the call light system
Correct Answer : D,E
A. Allowing the patient to ambulate independently: This intervention is not appropriate for a patient who scores 30 points on the Morse Fall Scale, which indicates a high risk of falling. The patient should be monitored closely and assisted with ambulation to prevent falls.
B. Administering a sedative to keep the patient calm: While it may be important to keep the patient calm, using sedatives should be approached with caution, as they can increase the risk of falls and impair judgment and coordination. This intervention is not the most appropriate approach to fall prevention.
C. Placing the patient in restraints: Restraints should be used only as a last resort and only when necessary to prevent harm to the patient or others. Using restraints can lead to physical and psychological harm and should not be the primary intervention for fall prevention.
D. Implementing a fall prevention protocol: This is the most appropriate intervention for a patient with a high risk of falling. A fall prevention protocol may include measures such as ensuring a clear path, using assistive devices, and conducting regular assessments of the patient's mobility and safety.
E. Educating the patient on using the call light system: This intervention is important for ensuring the patient feels safe and can call for assistance when needed. Educating the patient on the call light system promotes communication and can help prevent falls by encouraging the patient to seek help when they need to move or ambulate.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. A client who is 1 day postoperative and has a nursing assistant helping him out of bed: While this client is at risk due to being postoperative, the presence of a nursing assistant provides additional support and assistance, which helps mitigate the risk of falling during this transition.
B. An older adult client who is confused and has urinary frequency: This client is at the greatest risk for a fall. Confusion can impair judgment and coordination, and urinary frequency can lead to hurried movements to the bathroom, increasing the likelihood of falls. Older adults are generally more susceptible to falls due to physiological changes, and the combination of confusion and the need for frequent trips to the bathroom heightens this risk significantly.
C. A client with diabetes mellitus who has a leg ulcer: Although this client may have mobility issues related to the leg ulcer, diabetes does not inherently increase the risk for falls as much as confusion and urinary frequency do. The focus would be on wound care rather than immediate fall risk.
D. An adolescent client who has a leg fracture and has been using crutches for the past 2 days: While this client is at risk due to the leg fracture and the use of crutches, they are likely to have received instruction on proper use of the crutches. If the client is following these instructions, the risk may not be as high as that of the confused older adult.
Correct Answer is C
Explanation
A. The client is attempting to remove the restraint: While this may indicate discomfort or agitation, it does not necessarily warrant loosening the restraint. The nurse should assess the underlying reasons for the client's behavior but may need to keep the restraint in place for safety if the client poses a risk to themselves or others.
B. The client has full range of motion in her wrist: Having full range of motion does not indicate a need to loosen the restraint. The primary concern with restraints is ensuring the client's safety and comfort while monitoring for signs of circulation and proper function.
C. The client's hand is cool and pale: This finding is concerning and indicates potential impaired circulation due to the restraint being too tight. Loosening the restraint is essential in this case to restore circulation and prevent further complications. Coolness and paleness are signs of inadequate blood flow and require immediate action to ensure the client’s safety.
D. The client has a capillary refill of less than 2 seconds: A capillary refill of less than 2 seconds typically indicates good circulation. While monitoring capillary refill is important, this finding alone does not warrant loosening the restraint. The priority is to respond to any indications of compromised circulation.
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