Author Question: When completing an admission assessment on an older adult, the nurse gives the patient a high fall ... (Read 158 times)

Cooldude101 · **on:** Jun 25, 2018

When completing an admission assessment on an older adult, the nurse gives the patient a high fall risk score. Which action should the nurse take first?

a. Use a bed alarm system on the patient's bed.
b. Administer the prescribed PRN sedative medication.
c. Ask the health care provider to order a vest restraint.
d. Place the patient in a geri-chair near the nurse's station.

Question 2

The nurse assesses an older patient who takes diuretics and has a possible urinary tract infection (UTI). Which action should the nurse take first?

a. Palpate over the suprapubic area.
b. Inspect for abdominal distention.
c. Question the patient about hematuria.
d. Invite the patient to use the bathroom.

scikid · **Reply #1 on:** Jun 25, 2018

Answer to Question 1

ANS: A
The use of the least restrictive restraint alternative is required. Physical or chemical restraints may be necessary, but the nurse's first action should be an alternative such as a bed alarm.

Answer to Question 2

ANS: D
Before beginning the assessment of an older patient with a UTI and on diuretics, the nurse should have the patient empty the bladder because bladder fullness or discomfort will distract from the patient's ability to provide accurate information. The patient may seem disoriented if distracted by pain or urgency. The physical assessment data are obtained after the patient is as comfortable as possible.