Which attempt by the family to prevent an older, frail adult from ...

[ETearle]

Which attempt by the family to prevent an older, frail adult from falling causes the home health nurse concern?
 
  a. Keeping several low wattage night-lights on in the evening
  b. Installing wooden railings on the stairway to the bathroom
  c. Keeping the side rails up on the client's bed at night
  d. Encouraging the client to use a cane when ambulating

Question 2

An 88-year-old woman is admitted to the hospital with a diagnosis of pneumonia. She has a his-tory of hypertension and congestive heart failure and is on a total of five different medications for these chronic conditions.
 
  The nurse caring for the woman develops a care plan that includes the diagnosis Risk for Falls. A priority nursing intervention for this client is to:
  a. perform a fall assessment.
  b. keep all of the side rails up on the client's bed at nighttime.
  c. place the client on bed rest so that she does not fall.
  d. assess the client's dietary intake for cal-cium adequacy.

[momo1250]

Answer to Question 1

ANS: C
Keeping side rails up have proven to be a risk factor for falls rather than a positive intervention. The remaining interventions are appropriate and generally effective.

Answer to Question 2

ANS: A
Completing a fall assessment will enable the nurse to identify and correct the risk factors for this patient. Side rails have not been found to be effective in keeping a client in bed and may actually lead to injury. Maintaining a patient on bed rest can lead to deconditioning and actually contrib-ute to falls. Assessing the client's dietary intake of calcium is a good intervention for this age group, but it is not a priority and will not prevent falls.

[ETearle]

Excellent

[T4T]

TYSM