Deck 12: Fall Prevention and Restraints

Question 1

The nurse is preparing to ambulate the client in the hall.Which action by the nurse is a strategy to reduce the client's risk of falls?

A)Encouraging client to wear nonskid footwear
B)Cautioning the client about cords or clutter on the floor
C)Encouraging the client to continue walking after complaints of feeling tired
D)Acting as the client's means of support instead of using a walker to provide additional support

Answer 1

Encouraging client to wear nonskid footwear

Question 2

The nurse completes yearly training regarding the use of restraints.Which situation would the nurse categorize as a restraint?

A)A safety belt applied across the client's waist when sitting in a geri chair with a quick release button demonstrated to the client
B)The use of the top side rail to provide something for the client to hold on to when getting out of bed
C)A safety belt around the infant when placing the child in a swing
D)The use of all four side rails on the bed after administering preoperative sedation

Answer 2

The use of all four side rails on the bed after administering preoperative sedation

Question 3

The nurse is instructing the unlicensed assistive personnel (UAP)on fall prevention for the clients.Which statement made by the UAP warrants further instruction?

A)"I will ensure that the call light is within reach of the client."
B)"I will make sure to have at least one side rail up at all times."
C)"I don't have to worry about the clients who are bedridden,as they are moved by the staff."
D)"I will make sure that the bed is in the lowest position prior to leaving the room."

Answer 3

"I don't have to worry about the clients who are bedridden,as they are moved by the staff."

Question 4

Prior to or immediately after applying restraints,the nurse must document the use of restraints in the medical record.Which item is not required in the documentation for this client?

A)Need for restraint was made clear to client and/or support people
B)Why the restraint was considered necessary
C)Type of restraint used
D)Health care provider's order for use of restraints

Question 5

The nurse is caring for a young pediatric client who is focused on pulling out the IV line in the right arm.Which type of restraint is the most appropriate for this client?

A)Elbow restraint to the right arm
B)Elbow restraint to the left arm
C)Mitt restraint to the right hand
D)Wrist restraint to the left arm

Question 6

The nurse is providing care to a client requiring restraints.How often does the nurse assess the client and document the assessment?

A)Once per shift
B)Once a day
C)Once every 4-6 hours
D)Once every 1-2 hours

Question 7

The nurse is providing care to a client who is diagnosed with paranoid schizophrenia.The client is threatening the staff and believes the staff is trying to harm him.When the nurse enters the client's room,the client is agitated,and attempts to slap the nurse.The nurse gets assistance from other staff members and restrains the client.Which nursing action is the priority at this time?

A)Requesting a psychiatric referral
B)Notifying the health care provider of the need to see the client within the hour
C)Padding the side rails
D)Obtaining consent from the client for use of restraints

Question 8

Which is required by the nurse prior to putting the bed or chair exit safety-monitoring device in place?

A)Obtaining a health care provider's order
B)Documenting the use of the alarm system
C)Testing the alarm
D)Applying the leg band or sensor pad

Question 9

The nurse is caring for a client who consistently pulls at the IV and urinary catheter.Restraints are applied that prevent the client from being able to grasp the tubing.Which term will the nurse use when documenting the restraints used for this client?

A)Jacket restraint
B)Limb restraint
C)Mitt restraint
D)Waist restraint

Question 10

Which action performed by the nurse will not reduce the risk of client falls?

A)Orienting clients to the unit and explaining how the call bell system works
B)Encouraging clients to use call bells for assistance and ensuring that the call bell is within easy reach
C)Placing overbed and bedside tables out of the way
D)Using nonskid mats in the tub or shower

Question 11

The nurse is providing care to a client who has an order for a jacket restraint.Which action by the nurse is appropriate when applying this restraint to the client?

A)Placing the vest with the opening on the side
B)Pulling the tie on the end of the vest flap across the chest and placing it through the slit on the same side of the chest
C)Using a slipknot to secure the tie around the solid leg of the bed frame
D)Using a half-bow knot to secure the tie around the movable bed frame

Question 12

The nurse administers an antianxiety (anxiolytic)medication to a client diagnosed with dementia who has been harming himself.When documenting the use of this medication as a restraint,which term is the most appropriate for the nurse to use?

A)Chemical restraint
B)Physical restraint
C)Medication restraint
D)Psychological restraint

Question 13

The unlicensed assistive personnel (UAP)informs the nurse that the client has pulled the IV catheter out again and is not oriented to time or place.Which task could the nurse safely delegate to the UAP at this time?

A)Applying wrist restraints
B)Calling the health care provider to obtain an order for restraints
C)Getting mitt restraints from the supply room and meeting the nurse in the client's room
D)Applying some form of restraint to limit the client's ability to pull the IV line out again

Question 14

When putting a client in restraints,the nurse will need to assess the client per policy.Which items will the nurse include when assessing this client?

A)The client's range of motion
B)That the client's restraint is tied in a knot
C)The client's vital signs
D)The client's circulation
E)The client's hydration

Question 15

The nurse is caring for a client who has seizure precautions.Which actions by the nurse are appropriate for these precautions?

A)Padding the bed around the head,foot,and side rails
B)Placing functional oral suction equipment in the room
C)Placing extremity restraints in the room for use if the client has a seizure
D)Keeping pillows handy to protect the client's head
E)Taping a bite block to the wall to protect the client from biting his or her tongue

Question 16

The nurse is working in a long-term care facility on a locked Alzheimer unit.Which client assigned to the nurse might require restraints?

A)The client who keeps getting out of bed at night and wandering the halls
B)The client who enters another client's room without reason and watches TV with the client in that room
C)The older adult client who spits at staff when they enter the room
D)The client who has numerous self-imposed scratches on the extremities

Question 17

The nurse is providing an explanation to the client who has a bed alarm.Which statement made by the client indicates an appropriate understanding of the use of a bed alarm?

A)"I can take the alarm off at any time."
B)"I will receive an electric shock if I get out of bed."
C)"The alarm will sound if I get out of bed."
D)"The alarm must be secured tightly against my inner thigh."

Question 18

The nurse is delegating supportive care to the unlicensed assistive personnel (UAP)for several clients on a medical-surgical unit.Which statement made by the UAP warrants the need for more information?

A)"I can untie the restraint when giving the client a bath."
B)"I will make sure to tie the restraint in a slip-knot."
C)"I will inform you of any changes to the skin."
D)"I will assist the client with hygiene."

Question 19

Which items are appropriate for the nurse to include when assessing a client for falls?

A)Reviewing for a history of falls before admission
B)Talking with family about concerns
C)Assessing the overall physical condition
D)Assessing medication lists
E)Assessing mental status