The nurse cares for a client with advanced Alzheimer disease who ...

[danielfitts88]

The nurse cares for a client with advanced Alzheimer disease who is not mobile. The nurse has assessed the client as high risk for falls. Which of the following should be included in the fall-prevention program? (Select all that apply.)
 
  A) Bright orange sticker on the resident's door
  B) Padded mattress on the floor next to the resident's bed
  C) Use of chest restraints when in the wheelchair
  D) Frequent assessment of resident for toileting needs
  E) Keep lights on in room and bathroom
  F) Place sensor pad alarm on bed

Question 2

A nursing home has been the site of numerous falls by residents in recent months. Which of the following environmental factors should the nurse manager change? (Select all that apply.)
 
  A) The hallways that lead to the dining room and common areas do not have handrails.
  B) Each room has a private sink and toilet but there are only two designated rooms for bathing in the facility.
  C) The bedrails on each resident's bed are kept in a raised position whenever the resident is in bed.
  D) The majority of care is provided by nursing assistants, with one registered nurse overseeing the care team.
  E) Medications are administered at each room by the nurse from a rolling cart.

[juwms]

Answer to Question 1

Ans: A, B, D, F
Bright ID stickers, padded mattress on the floor, frequent assessment, and a bed alarm are all appropriate interventions; lights on and use of restraints are not.

Answer to Question 2

Ans: A, C
Keeping bedrails raised can constitute a falls risk when residents attempt to leave their bed to go to the washroom and are forced to scale the bedrails. Long hallways, shared bathing facilities, and the particular skills mix of the facility are unlikely to contribute directly to the high incidence of falls.

[danielfitts88]

TYSM

[bdobbins]

Wow, this really help