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 B

Explanation

A. Stand with the knees locked: Locking the knees can lead to instability and increase the risk of injury to both caregivers. It is important to maintain flexibility in the knees to facilitate movement and maintain balance while performing transfers.

B. Flex the hips and knees: This posture helps both caregivers maintain a low center of gravity and utilize their leg muscles for lifting and moving, which is essential for preventing injury. By bending at the hips and knees, caregivers can exert more force while reducing the strain on their backs, ensuring a safer transfer for both the patient and themselves.

C. Shift the body weight from the front leg to the back leg: While shifting body weight is important during lifting, it is more effective when done in conjunction with bending at the hips and knees. This option does not provide the most optimal posture for lifting and moving the patient safely.

D. Stand with the feet together: Standing with feet together decreases stability and balance, which can increase the risk of falling or injury during a transfer. Caregivers should stand with their feet shoulder-width apart to enhance their base of support and provide better stability while moving a patient.

A. Interpersonal B. Intrapersonal C. Group D. Small group

Correct Answer is A

Explanation

A. Interpersonal: The nurse is engaging in interpersonal communication during the admission health history and physical assessment. This form of communication occurs between two individuals and involves a direct exchange of information, thoughts, and feelings. The nurse and the patient interact in a one-on-one setting to gather health information and build rapport.

B. Intrapersonal: Intrapersonal communication refers to communication that occurs within an individual, such as self-talk or internal dialogue. This is not the form of communication used during the nurse's interaction with the patient.

C. Group: Group communication involves interactions among multiple individuals, such as a discussion or meeting with several participants. This does not apply to the nurse's one-on-one interview with the patient.

D. Small group: Small group communication typically involves a few people discussing or working together on a task or topic. Although the nurse may participate in small group discussions, the specific interaction during the admission assessment is classified as interpersonal communication.

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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

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