A nurse completes the Pediatric Fall Risk Assessment on a patient ...

[asan beg]

A nurse completes the Pediatric Fall Risk Assessment on a patient who scores a 9. Which intervention by the nurse is most important to include on the care plan?
 
  A.
  Allow independent ambulation around the unit.
  B.
  Maintain forced bedrest with restraints if necessary.
  C.
  Provide assistance with transfers and ambulation.
  D.
  Use two individuals at all times for mobility.

Question 2

A nurse is caring for a patient in Crutchfield tongs. Which assessment finding requires immediate notification to the health-care provider?
 
  A.
  Altered mental status
  B.
  Crusted drainage at pin sites
  C.
  Irritability and pain
  D.
  WBCs of 98,000/mm3

[djofnc]

Answer to Question 1

ANS: C
A pediatric fall risk score of 0 to 7 demonstrates low risk for falls, whereas a score of 8 to 17 indicates a high risk for falls. Because this child demonstrates a high risk for falls he or she should have assistance with transfers and walking.

Answer to Question 2

ANS: A
Crutchfield tongs are inserted into the skull. Any alteration in mental status could signify a serious complication, such as infection or intracranial bleeding (both are rare but possible). The nurse would not need to report crusted drainage, irritability and pain, or a normal white blood cell count.

[asan beg]

TYSM

[miss.ashley]

Excellent