An older patient has fallen twice in the hospital in the last 2 ...

[burton19126]

An older patient has fallen twice in the hospital in the last 2 days. What action by the nurse is best?
 
  a. Request restraint orders from the provider.
  b. Assess the patient for undiagnosed illness.
  c. Remind the patient to call for help getting up.
  d. Have a family member stay with the pa-tient.

Question 2

An older patient diagnosed with dementia has begun behaviors that increase the risk of falling. The patient's son tells the nurse that physical restraints may be used. The nurse responds
 
  a. I'll document that, so that the staff can use them when necessary.
  b. Physical restraints are seldom effective on patients with dementia.
  c. The staff will use physical restraints only as a last resort.
  d. There are more effective methods to use to help ensure her safety.

[cadimas]

Answer to Question 1

B
Falls are commonly associated with a new onset of illness in the older patient. The nurse assesses for this possibility. Restraints are a last resort. The patient may be too confused or forgetful to remember to call for help, plus this places the responsibility for safety on the patient. Family members may not be present or able to stay with the patient continuously.

Answer to Question 2

D
Physical restraint use does not prevent falls and therefore should never be employed for safety precautions. This is the best explanation because the nurse will then need to explain the other measures that will be taken to keep the patient safe.