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mobility
mobility avoid falling
| Question | Answer |
|---|---|
| old patient has just been admitted to the hospital after a fall. The patient has an injury to her ankle and thus requires assistance with ambulation. She has periods of confusion requiring you to implement measures to provide a restraint-free environment. | Use stress reduction techniques. Orient the patient and her family to the surroundings and staffUse a pressure-sensitive alarm. Organize the patient's day with a predictable routine. Use a wedge pillow on the chair. |
| The proper use of side rails can prevent patient injury. In which situations would you raise three of four rails, with two up at head of bed? | When the patient is confused When the patient is in a weak stateWhen the patient is sedated |
| Which of the evaluation measures determines whether this expected outcome was met? | Communicate with nurse/charge nurse from previous shift to learn if patient experienced any falls while on the unit. |
| 1. Perform the timed Get Up and Go Test 2. You open the curtains and look around the patient's room 3. You note that the patient takes an antihypertensive. | 1. This determines whether the patient needs assistance to ambulate 2. This identifies environmental risk factors for falls such as poor lighting, wet floors, cluttered pathway, etc. 3. Specific classes of medications may cause hypotension |
| 4.You note that the patient requires opioids for pain management 5. You determine whether the patient has glasses or a hearing aid.- 6. You talk with the patient to assess memory, ability to identify objects, and orientation.- | 4.This identifies environmental risk factors for falls such as poor lighting, wet floors, 5.Sensory impairments increase a patient's physical risk for falls 6.Physiologic alterations such as impaired cognition increase a patient's risk for falls |
| An elderly patient was recently admitted to a medical unit with severe fluid and electrolyte imbalance. His family states that he has periods of confusion. What are some practical precautions the nurse can take to ensure the patient's safety without havin |
Created by:
Nurusky
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