A patient has reduced muscle strength after a left-sided stroke and is at risk for falling.Which intervention is most appropriate for the nursing diagnosis 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.

Question

Quizplus · Accepted Answer

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;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 that a staff member can quickly get to the room and assist the patient if necessary.

A Patient Has Reduced Muscle Strength After a Left-Sided Stroke