# Situation: The public health nurse visits a family in which the grandfather, 76, has type 2 diabetes with blood sugar that stays high and was recently found to have early dementia. His wife, 70, cares for him and is scheduled for cataract surgery next month. Their son, 45, who lives with them, collects the grandfather's monthly pension. The house has loose rugs and a dimly lit stairway, and the grandfather fell once last month. The grandfather sleeps in a hospital-type bed borrowed from a relative. The nurse teaches the wife how to prevent falls at home. Which statement by the wife shows that she needs **FURTHER** teaching?

> source: MyMerci (mymerci.kr)  
> url: https://mymerci.kr/pages/nclex_q.php?qn_id=627245  
> language: ko  
> subject: Nursing Practice I — Community Health Nursing

## 문제

Situation: The public health nurse visits a family in which the grandfather, 76, has type 2 diabetes with blood sugar that stays high and was recently found to have early dementia. His wife, 70, cares for him and is scheduled for cataract surgery next month. Their son, 45, who lives with them, collects the grandfather's monthly pension. The house has loose rugs and a dimly lit stairway, and the grandfather fell once last month.

The grandfather sleeps in a hospital-type bed borrowed from a relative. The nurse teaches the wife how to prevent falls at home. Which statement by the wife shows that she needs **FURTHER** teaching?

## 보기

1. "I will put a night-light along the way to the bathroom."
2. "I will make sure he wears slippers with nonskid soles."
3. "I will raise all the side rails at night so he cannot get up." **✔ 정답**
4. "I will have him sit on the edge of the bed before he stands."

**정답: 3**

## 해설

Raising all side rails to keep a confused person in bed does not reliably prevent falls: he may climb over them or become trapped, and rails used to prevent voluntary exit act as a restraint. Lighting the path, sitting before standing to prevent dizziness on rising, and nonskid footwear are correct fall-prevention measures.

## 심화 해설

Why option 3 requires further teaching

The wife’s statement about raising all side rails at night reflects a common but unsafe assumption: that a physical barrier will reliably keep a confused older adult in bed. In reality, using side rails to prevent voluntary exit functions as a restraint and does not reliably prevent falls. A person with early dementia may attempt to climb over the rails, which can result in a fall from a greater height, or may become trapped between the rail and the mattress, causing injury or entrapment-related asphyxia. Because the grandfather has both type 2 diabetes with persistent hyperglycemia and early dementia, he is at increased risk for nighttime confusion, nocturia, and unsteady mobility—making full rail elevation especially hazardous.

Watch out! In nursing licensure exams, any intervention that restricts a patient’s freedom of movement for the purpose of preventing falls—such as raising all four side rails—is classified as a restraint and requires a provider order, ongoing assessment, and documentation. It is not a first-line fall prevention strategy.

Why the other statements are correct

Option 1: Night-light along the bathroom path. Older adults with dementia and diabetes frequently wake at night to urinate. A dimly lit stairway and loose rugs were already identified hazards in the home. Improving lighting along the route to the bathroom reduces fall risk by enhancing visual orientation and depth perception, which are often impaired in older adults and further compromised by cognitive decline.

Option 2: Nonskid slippers. Footwear with slip-resistant soles directly addresses traction on smooth or loose surfaces. In the context of this home—which has loose rugs—nonskid footwear is a targeted, evidence-aligned environmental modification that reduces the likelihood of slipping during transfers and ambulation.

Option 4: Sitting on the edge of the bed before standing. This addresses orthostatic hypotension, a common concern in older adults with diabetes, especially if autonomic dysfunction or dehydration is present. Pausing in a seated position before standing allows blood pressure to adjust and reduces dizziness-related falls. This is a standard, safe mobility technique that does not restrict the patient.

Clinical reasoning for the PNLE/NCLEX

The question tests whether the examinee can distinguish environmental safety measures from restraint use. The grandfather’s fall risk is multifactorial: prior fall within the past month, dementia, diabetes with poor glycemic control, home hazards, and a borrowed hospital-type bed. The nurse’s teaching should emphasize mobility support, environmental modification, and safe transfer techniques—not containment.

| Intervention | Fall prevention mechanism | Restraint concern |
| --- | --- | --- |
| Night-light to bathroom | Improves visual cues and orientation at night | None |
| Nonskid slippers | Increases traction on loose or smooth surfaces | None |
| Sit at edge of bed before standing | Allows BP adjustment; reduces orthostatic dizziness | None |
| Raise all side rails at night | Intended to prevent exit but may cause climbing or entrapment | Yes—acts as a restraint |

Key point! If a confused patient is at high risk for nighttime falls, safer alternatives include lowering the bed to the lowest position, placing the mattress on the floor if appropriate, using a bed alarm, or increasing supervision—not raising all side rails.

## 임상 시나리오

Fall Prevention in Home Care for Older Adults with DementiaSafe mobility strategies and restraint avoidance
Raising all side rails to keep a confused older adult in bed functions as a restraint and does not reliably prevent falls. A person with dementia may attempt to climb over the rails, falling from a greater height, or become entrapped between the rail and mattress, risking injury or asphyxia.

Effective home fall prevention includes placing a night-light along the path to the bathroom to improve visual orientation, ensuring nonskid footwear for traction, and having the person sit on the edge of the bed before standing to prevent orthostatic hypotension.

CautionAny intervention that restricts movement to prevent falls, such as raising all four side rails, is classified as a restraint and requires a provider order, ongoing assessment, and documentation. It is not a first-line fall prevention strategy.

## 핵심 개념

- **restraint** — Any device or method that limits a person's freedom of movement and is not a usual part of treatment; using side rails to prevent voluntary exit is classified as a restraint.
- **entrapment** — A serious safety event in which a person becomes caught between bed rails and the mattress, potentially causing injury or asphyxia.
- **orthostatic hypotension** — A drop in blood pressure upon standing that can cause dizziness or fainting; sitting on the edge of the bed before standing helps prevent it.
- **nocturia** — The need to wake at night to urinate, common in older adults and those with diabetes, increasing nighttime fall risk.

## 같은 주제 문제

- [Situation: The public health nurse makes a home visit to a family. The father, 58, a drive…](https://mymerci.kr/pages/nclex_q.php?qn_id=627034)
- [Situation: The public health nurse makes a home visit to a family. The father, 58, a drive…](https://mymerci.kr/pages/nclex_q.php?qn_id=627035)
- [Situation: The public health nurse visits a family of six in a farming barangay. The grand…](https://mymerci.kr/pages/nclex_q.php?qn_id=627045)
- [Situation: The public health nurse visits a family of six in a farming barangay. The grand…](https://mymerci.kr/pages/nclex_q.php?qn_id=627046)
- [Situation: The public health nurse visits a family of six in a farming barangay. The grand…](https://mymerci.kr/pages/nclex_q.php?qn_id=627047)
- [Situation: The public health nurse visits a family of six in a farming barangay. The grand…](https://mymerci.kr/pages/nclex_q.php?qn_id=627048)
- [Situation: The public health nurse visits a family of six in a farming barangay. The grand…](https://mymerci.kr/pages/nclex_q.php?qn_id=627049)
- [Situation: During a follow-up home visit, the nurse learns that the father, 38, lost his j…](https://mymerci.kr/pages/nclex_q.php?qn_id=627050)

---

More free questions: [기출문제](https://mymerci.kr/)

_학습 참고용입니다. 실제 임상은 최신 지침과 소속 기관 프로토콜을 따르세요._