Difficulty: Medium
Average Score: 74%
Simulated
A nurse is caring for a client who had a cerebrovascular accident and is at risk for falls. The nurse should recognize that which of the following is an appropriate safety precaution?
Correct answer
A
Rationale
Correct Answer: A - Monitor the client at least once every hr.
Rationale: Continuous monitoring allows for early detection of any signs of impending falls, enabling prompt intervention. This precaution helps ensure the client's safety without restricting mobility unnecessarily.
Summary of Incorrect Choices:
B: Assigning a private room may not address the risk of falls adequately.
C: Requesting restraints should be a last resort due to ethical and legal implications.
D: Keeping all four side rails up can lead to feelings of confinement and increase the risk of injury if the client tries to climb over them.
Rationale: Continuous monitoring allows for early detection of any signs of impending falls, enabling prompt intervention. This precaution helps ensure the client's safety without restricting mobility unnecessarily.
Summary of Incorrect Choices:
B: Assigning a private room may not address the risk of falls adequately.
C: Requesting restraints should be a last resort due to ethical and legal implications.
D: Keeping all four side rails up can lead to feelings of confinement and increase the risk of injury if the client tries to climb over them.