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

Answer and Explanation

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.

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Correct Answer is D

Explanation

A. Vigorously brush the client's teeth: Vigorous brushing is not appropriate for an unconscious client. It can cause trauma to the gums or teeth and increase the risk of aspiration if the client has any residual secretions or fluids in the mouth. Gentle brushing should be employed to avoid injury.

B. Hold the toothbrush at a 90° angle: Holding the toothbrush at a 90° angle is not necessary for clients who are unconscious. A more effective angle may be around 45° to effectively clean the surfaces of the teeth while minimizing the risk of gagging or aspiration.

C. Place two fingers in the client's mouth: This action could be harmful, as placing fingers in the mouth of an unconscious client poses a risk of injury or could inadvertently trigger a gag reflex. Instead, proper oral care should be conducted using appropriate tools without placing fingers inside the mouth.

D. Turn the client to the side: Turning the client to the side is the best action as it helps prevent aspiration of secretions or fluids during oral care. This position allows for safer access to the mouth while also promoting drainage of any excess fluids, reducing the risk of choking or aspiration pneumonia.

A. Middle-aged man experiencing the acute phase of myocardial infarction (MI) B. Older adult with a history of dementia admitted for dehydration C. Young adult in the rehabilitative phase after arthroscopic surgery D. Middle-aged woman just diagnosed with terminal lung cancer

Correct Answer is A

Explanation

A. Middle-aged man experiencing the acute phase of myocardial infarction (MI): During the acute phase of an MI, the patient may be experiencing significant physical and emotional stress. Touch may be perceived as intrusive or overwhelming, particularly if the patient is in pain or experiencing anxiety. It's important for the nurse to use caution with touch in this situation, prioritizing verbal communication and ensuring the patient's comfort.

B. Older adult with a history of dementia admitted for dehydration: Touch can often be comforting for individuals with dementia, as it may help to reduce anxiety and provide reassurance. In this case, touch may be beneficial as long as the nurse assesses the individual’s response to touch and proceeds accordingly.

C. Young adult in the rehabilitative phase after arthroscopic surgery: This patient may appreciate touch as a form of encouragement or support during rehabilitation. Unless there are specific contraindications, touch is generally acceptable in this context.

D. Middle-aged woman just diagnosed with terminal lung cancer: While this patient may benefit from touch as a source of comfort and support, the nurse should be sensitive to the patient's emotional state. However, compared to the patient in acute MI, the nurse is less likely to need to use touch cautiously in this situation.

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Which of the following interventions is most appropriate for a patient that gets 30 points on the Morse Fall Scale? (Select All that Apply.)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is performing oral care for a client who is unconscious. Which of the following actions should the nurse take?

Correct Answer is D

Explanation

The nurse is assigned to the care of the following patients. In planning nursing care, the nurse knows to use touch cautiously when communicating with which patient?

Correct Answer is A

Explanation

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Which of the following interventions is most appropriate for a patient that gets 30 points on the Morse Fall Scale? (Select All that Apply.)

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