The nurse is caring for a 79-year-old man who has a non-weight-bearing cast on the left lower extremity. The client ambulates without using a walker despite repeated instruction from the nurse
Which response by the nurse is most likely to keep the client from falling? 1. Apply a vest restraint and offer frequent toileting.
2. Plan fall prevention with client, family, and provider.
3. Inform family that the client needs physical restraints.
4. Document that the client has a high potential for falling.
2
2. Planning an individualized fall prevention program with the help of the client, family, and provider is more likely to reduce this client's risk of falls because the client gains some control over the plan of care and still benefits from the input of the provider, family, and nurse and the fall prevention program. Including the client in planning also gives the client ownership of the plan, making it less likely that the client will disregard a plan he helped to design.
1. Vest restraints are associated with serious injuries and are not recommended for use.
3. The nurse informs the family before applying restraints to comply with nursing and legal standards; however, applying restraints may increase the risk of falls and thereby justifying the nurse's attempts to exhaust alternative methods of engaging the client in the plan before resorting to restraints.
4. Documenting the client's risk is important because it communicates the information and records the nurse's acknowledgment of the risk, but it is not as effective as engaging the client in planning care as a prevention technique because it is indirect.
You might also like to view...
Which unexpected circumstance best defines a fall?
a. Falls to the ground, floor, or lower level b. Loses consciousness, resulting in injury c. Loses balance, resulting from a lack of equilibrium d. Injures self, resulting from a side effect of a medication
The nurse is caring for a client who is from a culture for which the nurse has a limited knowledge base. The nurse conducts the admission interview using cultural humility. Which should the nurse ask in the interview? (Select all that apply.)
A) Yes or no questions B) About traditions C) Open-ended questions D) How the client has addressed the illness E) If the cause of the illness is spiritual
The majority of long-term care residents are
a. terminally ill. b. without other family members. c. physically disabled. d. elderly people.
The nurse is assessing a patient's functional ability. Which patient best demonstrates the definition of functional ability?
a. Considers self as a healthy individual; uses cane for stability b. College educated; travels frequently; can balance a checkbook c. Works out daily, reads well, cooks, and cleans house on the weekends d. Healthy individual, volunteers at church, works part time, takes care of family and house