A patient has reduced muscle strength following a left-sided stroke and is at risk for falling. Which intervention is most appropriate for the nursing diagnostic statement, Risk for falls?
a. Encourage patient to remain in bed most of the shift.
b. Keep all side rails down at all times.
c. Place patient in room away from the nurses' station if possible.
d. Assist patient into and out of bed every 6 hours or as tolerated.
ANS: D
Risk for falls is a potential nursing diagnosis; therefore the nurse needs to implement actions that will prevent a fall. Assisting the patient into and out of bed is the most appropriate intervention to prevent the patient from falling. Encouraging activity builds muscle strength, and helping the patient with transfers ensures patient safety. Encouraging the patient to stay in bed will not promote muscle strength. Decreased muscle strength is the risk factor placing the patient in jeopardy of falling. The side rails should be up, not down, according to agency policy. This will remind the patent to ask for help to get up and will keep the patient from rolling out of bed. The patient should be placed near the nurses' station, so a staff member can quickly get to the room and assist the patient if necessary.
You might also like to view...
An initiative has been launched in a large hospital to promote the use of "people-first" language in formal and informal communication. What is the significance to the patient when the nurse uses "people-first" language?
A) The nurse knows more clearly who the patient is. B) The person is of more importance to the nurse than the disability. C) The patient's disability is the defining characteristic of the patient's life. D) The nurse knows that the patient's disability is a curable condition.
A nurse is planning to teach a prenatal class on the Dick-Read method of childbirth. Which information should the nurse plan to include?
A. After birth, the newborn is placed in a tub of warm water. B. Consciously controlled breathing is the main coping strategy. C. Relaxation is vital because pain is caused by fear and tension. D. The Dick-Read method means a totally medication-free birth.
The nurse is performing a physical assessment on a 3-year-old child. The parents state that the child excessively rubs the eyes and often tilts the head to one side
What visual impairment should the nurse suspect? a. Strabismus b. Astigmatism c. Hyperopia, or farsightedness d. Myopia, or nearsightedness
258.7 รท 100 = ____________________
Fill in the blank(s) with correct word