SAFETY CHAPTER

The older adult will have an increased risk for developing which of the following? Heatstroke Fire hazards Poisoning Gunshot wounds

Heatstroke

One of the leading causes of death in the United States, particularly in southwestern states, is drowning. How can the nurse assist in lowering this statistic? Implement drowning-prevention strategies. Require fencing around all pools. Begin swim lessons with toddlers. Educate children in cardiopulmonary resuscitation.

Implement drowning-prevention strategies. The principles of injury control have interventions centered at three primary levels: the individual level, providing education about safety hazards and prevention strategies; the design phase, using engineering and environmental controls; and the regulatory level, creating, monitoring, and enforcing regulations to ensure safe products and environments among manufacturers, retailers, employers, workers, and product users.

The unlicensed assistive personnel (UAP) tells the nurse that a client is very confused and trying to get out of bed without assistance. What is the appropriate action by the nurse? Put up all four side rails on the bed. Initiate use of a bed alarm. Administer the client's sedative as ordered. Contact the physician for a restraint order.

Initiate use of a bed alarm. To prevent a fall, the nurse should attempt to prevent the confused client from getting out of bed by himself by using the least restrictive action first. In this case, it would be to initiate the use of a bed alarm. Putting up all four side rails and use of a sedative are considered forms of restraints, and restraints should be used only as a last resort when the client is in danger of harming himself or others. Contacting the physician for a restraint order or sedative is appropriate if the least restrictive measures do not work.

A nurse working in a long-term care facility institutes interventions to prevent falls in the older adult population. Which intervention would be an appropriate alternative to the use of restraints for ensuring client safety and preventing falls? Involve family members in the client's care. Keep the client sedated with tranquilizers. Allow the client to use the bathroom independently. Maintain a high bed position so the client will not attempt to get out unassisted.

Involve family members in the client's care. Family members are an invaluable resource in assessing a client's risk for a fall because they can provide information regarding periods of weakness, confusion/disorientation, and a history of unreported falls. Allowing the client to ambulate independently may further increase the risk of a fall. Sedating a client is a form of chemical restraint, and may cause the client to have an unsteady gait when ambulating. If the client attempts to get out of bed a high bed position would cause more injury to the client if a fall occurs.

A school nurse is providing information to a group of older adults during Fire Prevention Week. Which statement is correct regarding fires in the home? Most home fires are caused by children playing with matches. Most fatal home fires occur while people are cooking. About 10% of home fire deaths occur in a home without a smoke detector.

Most people who die in house fires die of smoke inhalation, rather than burns. Most people who die in house fires die of smoke inhalation, rather than burns. About 50% of home fire deaths occur in a home without a smoke detector. Many home fires are started because someone fell asleep smoking in bed or on a sofa, and most fatal home fires occur while people are sleeping.

During a course on terrorism, a group of emergency room nurses learns about terrorists who use bombs or other explosives to inflict injury on numerous people and cause multiple fatalities. This is an example of: chemical terrorism. bioterrorism. nuclear terrorism. mass trauma terrorism.

mass trauma terrorism.

Which safety tip could the nurse give to parents to help decrease the risk of the leading cause of injury or death in children 1 to 4 years of age? "Always provide close supervision for young children when they are in or around pools and bathtubs." "Store medications in a locked area to prevent children from getting into them." "Never keep firearms in the home with young children." "Never smoke in the bed in the house when young children are present."

"Always provide close supervision for young children when they are in or around pools and bathtubs."

A nurse is educating the family caregiver of an older adult client about measures to promote client safety in the home. What would be most appropriate to include? "Keep all medications within the client's reach." "Avoid the use of nightlights in the client's bedroom." "Clear the clutter from the stairways and walkways." "Get the client immunized against whooping cough."

"Clear the clutter from the stairways and walkways."

A large health care organization has committed to promoting a just culture when adverse events and near misses take place. Which question will guide the organization's response when a nurse commits an error? "Have the client and the family been informed about this?" "How have other organizations responded to nurses in events like this?" "What is the organization's legal liability in this matter?" "How did the nurse's actions contribute to this error?"

"How did the nurse's actions contribute to this error?"

The nurse is conducting a community education program on bike helmet safety. The nurse determines additional information is needed when a participant states: "The helmet should rest 1 inch above the eyebrows." "I should be able to fit two fingers under the chin strap." "My child needs a helmet if he is in a secured passenger bike seat." "My child should wear a helmet every time he rides a bike."

"I should be able to fit two fingers under the chin strap."

The nurse is teaching an unlicensed assistive personnel (UAP) about fire safety. Which UAP statement demonstrates that teaching has been effective? "I will sound the alarm before I start moving a patient from a room." "I will leave all doors open after rescuing patients." "I will rescue clients from harm before doing anything else." "I know that nurses are the only ones who can extinguish a fire."

"I will rescue clients from harm before doing anything else."

A school nurse is conducting a safety seminar with students in 6th grade. Which teaching point is most important? "A wood-burning fireplace is a major fire risk, and it shouldn't be used unless necessary." "If your clothes should catch on fire, go to an open area as quickly as possible." "Make sure that your family's microwave oven was made after 1999; otherwise, it may be a fire risk." "Make sure that you have smoke detectors in your house and that they're in working order."

"Make sure that you have smoke detectors in your house and that they're in working order." A paramount fire-safety issue is smoke detectors, since approximately half of home fire deaths occur in a home without a smoke detector. This risk far exceeds that of fireplaces, even though these must be used with caution. Individuals should stop, drop and roll if clothing catches on fire. Old microwaves do not constitute a significant fire risk.

The nurse is teaching an unlicensed assistive personnel (UAP) about fire safety. Which UAP statement requires immediate nursing intervention? "I will close the door to the room where the fire is, after clients have been removed." "I will rescue clients from harm before doing anything else." "After clients are evacuated from the room with the fire, the alarm can be sounded." "Only certain members of the healthcare team can extinguish a fire."

"Only certain members of the healthcare team can extinguish a fire."

A nurse is teaching a community group about bicycle safety. Which statement should be included when creating a teaching plan regarding bicycle safety? "Parents are effective role models for children when they also wear helmets while riding." "The chin strap on the helmet should be adjusted to fit loosely so that it does not choke the child." "Any helmet is appropriate for bicycle riding because all children should wear helmets when riding." "Young children secured in a bicycle passenger seat do not have to wear a helmet."

"Parents are effective role models for children when they also wear helmets while riding." Parents are effective role models for children when they also wear helmets while riding. Helmets that have been damaged in a crash should not be worn. The chin strap should fit snuggly, not loosely. Young children who are secured in a bicycle passenger seat must also wear a helmet.

The nurse is assessing an adolescent with an annual physical. The mother reports that she has noticed a change in the child's behavior lately, including mood swings, withdrawal from the family, and failing school grades. The mother does not know what to do and asks the nurse for guidance. What is the most appropriate guidance from the nurse? "This is typical adolescent behavior. Ignore it and it will improve." "Adolescents are generally difficult children. Sometimes punishment is necessary to make them change their attitudes." "These could be signs of substance abuse. Open communication and seeing a counselor who specializes in substance abuse would be beneficial." "Let's admit your child to an acute care facility so that we can run more tests."

"These could be signs of substance abuse. Open communication and seeing a counselor who specializes in substance abuse would be beneficial." Some signs of substance abuse in adolescents include mood swings, withdrawal from the family, and failing school grades. The other statements are inappropriate generalizations and do not address the problem. There is not enough evidence to suggest a need for hospital admission.

Which statement indicates that a family understands the teaching that has been provided by the nurse related to car seat safety for their 3-year-old child? "We place our child in a front-facing car seat in the front of the car." "We place our child in a rear-facing car seat in the back seat of the car." "We place our child in a rear-facing car seat in the front of the car." "We place our child in a front-facing car seat in the back seat of the car."

"We place our child in a front-facing car seat in the back seat of the car."

The community health nurse is talking with four clients. Who does the nurse identify that would most benefit from teaching about alcohol and drug abuse? 19-year-old male college student majoring in physics 40-year-old female who is working two jobs 25-year-old female who just accepted her first job 34-year-old male who does not use a seat belt

19-year-old male college student majoring in physics Young adults, particularly those who just became emancipated from parental supervision, are at highest risk for alcohol and drug abuse. Other clients may have other safety risk factors, but are not at a proportionately higher risk for alcohol and drug abuse.

Which nurse would be at the highest risk of causing a hazardous situation? A nurse who has worked 32 hours of overtime this week A nurse who has placed a client in the bed with three side rails up A nurse who is administering medications to four clients A nurse who is transferred to another unit to assist with care

A nurse who has worked 32 hours of overtime this week

A new mother inquires about the use of a car seat for her infant. Which information provided by the nurse is most accurate regarding the use of a rear-facing safety seat for an infant? A rear-facing safety seat should be used for infants younger than 1 year old and weighing more than 20 lb (9 kg). A rear-facing safety seat should be used for infants younger than 1 year old or up to the maximum weight for the seat. A rear-facing safety seat should be used for infants and toddlers younger than 2 years old and weighing less than 20 lb (9 kg). A rear-facing safety seat should be used for infants and toddlers younger than 2 years old or up to the maximum weight for the seat.

A rear-facing safety seat should be used for infants and toddlers younger than 2 years old or up to the maximum weight for the seat. Infants and toddlers up to 2 years of age (or up to the maximum height and weight for the seat) should remain in a rear-facing safety seat.

A school nurse is teaching a group of adolescents about safe driving. What behaviors should the nurse encourage in order to help prevent motor vehicle accidents? Select all that apply. Obey the speed limit. Always wear a seat belt. Drive at night when fewer people are on the road. Limit the number of other adolescents in the car. Never text while driving.

Always wear a seat belt. Limit the number of other adolescents in the car. Never text while driving. Obey the speed limit.

The nurse has just admitted a client with a latex allergy to the medical-surgical nursing floor. Which is the priority nursing intervention? Notify the interdisciplinary healthcare team to use nonlatex equipment. Flag the room door. Apply an allergy-alert identification bracelet on the client. Teach client to wear Medic-Alert bracelet.

Apply an allergy-alert identification bracelet on the client.

The nurse overhears an older adult client's son talking to her in a very aggressive and violent way. When the nurse walks into the room, the son changes and speaks kindly to his mother and the health care providers. What should the nurse do about this observation? Report the suspicions to to the authorities. Nothing, as it is none of the nurse's concern. Ask to examine the client alone in order to speak to her privately. Document the observed behaviors in the client's chart.

Ask to examine the client alone in order to speak to her privately.

A school-age child is admitted to the emergency room with the diagnosis of a concussion following a collision when playing football. After the collision, the parents state that he was "knocked out" for a few minutes before recognizing his surroundings. What is the priority assessment when the nurse first sees the client? Evaluation of all of his cranial nerves Assessment of vital signs and respiratory status Initiation of a peripheral intravenous (IV) line for fluid administration Assessment of head circumference

Assessment of vital signs and respiratory status Assessment after a head injury includes immediate evaluation of airway, breathing, and circulation. Therefore, assessment of vital signs and respiratory status is a priority for this client. Head circumference is only beneficial in children less than 2 years old and/or with open fontanels. Evaluation of all of his cranial nerves does not take priority over cardiopulmonary assessment. Assessment comes before intervention in the nursing process and more assessment is needed for this client before the need for an IV line is determined.

What is the most important safety concept that a nurse should include in the teaching plan for a family with a newborn infant in the household? Include safeguards to prevent falls in the home. Educate about, and be aware of, signs of risky behaviors. Teach seat belt safety. Avoid stuffed animals and blankets in the crib.

Avoid stuffed animals and blankets in the crib. Suffocation is a hazard for infants, especially before the age of 4 months. Toddlers and older children are more at risk for falls, and adolescents tend to engage in risky behaviors. Therefore, education about, and awareness of, these behaviors is important in this age group, but not for an infant. Seat belt safety is more appropriate to teach older children and adults. Car seat safety would be important for families with a newborn infant.

A nurse is educating parents of preschoolers on appropriate safety measures for this age group. What might be a focus of the education plan? Childproofing the house Gun safety Smoking cessation Fire safety

Childproofing the house

The nurse is reviewing a healthcare provider's orders in the electronic health record (EHR) and notices several abbreviations. What is the appropriate nursing action? Confirm abbreviations with another nurse. Administer medications as ordered. Contact healthcare provider to clarify order. Fix the abbreviations in the EHR.

Contact healthcare provider to clarify order. Before treatments can safely be carried out and medications safely given, the nurse must contact the healthcare provider to clarify the orders. Many abbreviations and symbols are not permitted for use in healthcare records. The nurse should never alter documentation, nor it is appropriate to confirm abbreviations with another nurse.

A child is playing soccer and is involved in a head-to-head collision with another player. Which assessment findings should the nurse be alert to that may indicate a concussion? Select all that apply. Vomiting Headache Fever Increased thirst Drowsiness

Drowsiness Headache Vomiting

The nurse is preparing to give an educational program to parents of toddlers related to promotion of safety. What should the nurse discuss with parents to reduce the risk of injury for this developmental stage? Select all that apply. Electrocution from outlets Ingestion of toxic medicine Falls from stairs Play-related injuries Accidental drowning

Falls from stairs Accidental drowning Electrocution from outlets

What best describes the nurse's role in disaster preparedness? Multiple roles, including triage and the distribution of resources Counseling the victims and families Administration of all of the medications Performance of all of the skills such as IV insertion and wound care

Multiple roles, including triage and the distribution of resources Nurses will perform multiple roles when assisting with a disaster, including triage, procedures, counseling, and distribution of resources.

Which level of health care provider may make the decision to apply physical restraints to a client? Senior personal care assistant LPN team leader RN nurse manager Nurse practitioner

Nurse practitioner Current evidence-based research has shown that physical restraints should only be used as a last resort, and only used to prevent injury to staff, clients, or others. Federal and state guidelines, as well as accrediting bodies, such as The Joint Commission, require that restraints be applied only when ordered by a prescriber such as a physician, nurse practitioner, or physician assistant.

A nurse is caring for a client who is receiving an intravenous therapy through an IV pump. Which intervention should the nurse implement to ensure electrical safety? Use an extension cord to provide freedom of movement. Run the electrical cord of the pump under the carpet. Tape the electrical cord of the pump to the floor. Obtain a three-prong grounded plug adapter.

Obtain a three-prong grounded plug adapter. The nurse should obtain a three-prong grounded plug adapter, as it carries any stray electricity back to the ground. Using an extension cord may be an electrical hazard. Taping the electrical cord to the ground and running the electrical cord under the carpet are not appropriate actions for electrical safety.

A client in a long-term care facility has become increasingly unsteady. The nurses are worried that the client will climb out of bed and fall. Which measure would be a priority recommendation for this client? Using restraints on the client to prevent a fall Placing the client in a bed with a bed alarm Raising all the side rails of the bed Providing a bed that is elevated from the floor

Placing the client in a bed with a bed alarm Raising all side rails on the bed would be a restraint, and may increase the client's risk of a fall if he or she climbs out of bed. Providing a bed that is elevated would put the client at a greater risk for a fall. Using restraints are not an option at this time, but placing the client in a bed with a bed alarm would help to prevent a fall.

What is the primary role of the nurse in the care of clients who experience domestic violence? Providing prompt recognition of the potential or actual threat to safety Calling the police Identifying health education and counseling measures for the family Serving as a witness in court

Providing prompt recognition of the potential or actual threat to safety The nurse is often the initial health care provider in contact with an abused child or a battered woman or man. Prompt recognition of the potential or actual threat to safety is crucial, and the nursing assessment may play a vital role in identifying a harmful environment.

A nurse responds to the call bell and finds another nurse evacuating the client from the room, which has caught fire. Which action should the nurse take? Pull the fire alarm lever. Evacuate the unit. Extinguish the fire. Confine the fire.

Pull the fire alarm lever.

The acronym health care workers use to remember the safety procedures in the event of fire is: RATE (relocate; advise; transport; extinguish). RACE (rescue; alarm; confine; evacuate). DAME (defend; action; move; evaluate). SILT (surround; initiate; liberate; transfer).

RACE (rescue; alarm; confine; evacuate). The correct acronym for health care facility fire safety is RACE.

The nurse is providing discharge teaching to the family of an older adult client. Which teaching will the nurse include to decrease the risk for electric shock? All machines that are used infrequently to remain plugged in. Remove the plug from the wall by pulling the electric cord. Leave outlets and switches open so air circulates through them. Refrain from using extension cords.

Refrain from using extension cords. Extension cords should not be used, so that overload is not placed on electric wires and circuits. For safest practices that decrease risk for electric shock, outlets and switches should be covered, machines that are used infrequently should be unplugged, and plugs should be removed from the wall by grasping the actual plug (not the cord).

The nurse is admitting a client to a medical-surgical unit who states, "If someone brings balloons to me, I might have trouble breathing." What is the appropriate nursing action? Keep balloons on opposite side of the client's room. Assure client that balloons do not cause breathing difficulties. Remind client that oranges and spinach can cause a cross-reaction. Replace common healthcare items with latex-free equipment.

Replace common healthcare items with latex-free equipment. The client has described a reaction to latex, so the environment should be as free from latex as possible. The nurse will replace all health care equipment with latex-free versions. The molecular structure of latex is similar to avocados, bananas, almonds, peaches, kiwi, and tomatoes; not oranges and spinach.

A nurse smells smoke and subsequently discovers a fire in a garbage can in a common area on the hospital unit. What is the nurse's priority action in this situation? Rescue anyone who is in immediate danger. Activate the fire alarm on the unit. Attempt to extinguish the fire. Evacuate clients and staff

Rescue anyone who is in immediate danger.

A nurse is preparing discharge education for a client with a newborn baby. What is the highest priority item that must be included in the education plan? Give warm bottles of formula to the baby. Lock all cabinets that contain cleaning supplies. Restrain the baby in a car seat. Keep all pots and pans in lower cabinets.

Restrain the baby in a car seat. The client should restrain the baby in a car seat when driving. Infants are especially vulnerable to injuries resulting from falling off changing tables or being unrestrained in automobiles. Locking the cabinets, giving warm bottles of formula to the baby, and keeping all pots and pans in lower cabinets are secondary teachings.

The nurse is creating a plan of care for the older adult who has multiple medications and a difficult time reading medication labels due to poor eyesight. What is the most appropriate nursing diagnosis to include in this client's plan of care? Risk for Falls related to immobility Risk for Poisoning related to poor eyesight and the inability to read medication labels Altered Sensory Perception related to decreased visual acuity Risk for Injury related to substance abuse

Risk for Poisoning related to poor eyesight and the inability to read medication labels Older adults are at an increased risk for falls and can have an altered sensory perception. However, neither of those diagnoses address this client's lack of vision, causing difficulty in reading the labels of his multiple medications and thereby causing a risk for injury by overdose. There is no indication of substance abuse in this client.

A father asks the nurse who is caring for his 13-year-old daughter why his daughter could be performing poorly in school lately, and why she is distancing herself from friends and family. Which of these possibilities would the nurse consider as the priority risk? She has lost interest in academics because she has a boyfriend now. She may be developing nutritional deficiencies from poor dietary habits. She may be beginning her menses. She may be the victim of cyber-bullying.

She may be the victim of cyber-bullying.

A nurse is assessing a client who was exposed to botulism from contaminated food supplies. Which symptom would the nurse expect to find in this client? Flu-like symptoms Petechial hemorrhages Skeletal muscle paralysis that progresses symmetrically and in a descending manner Skin lesion with local edema that progresses, enlarges, ulcerates, and becomes necrotic

Skeletal muscle paralysis that progresses symmetrically and in a descending manner

Which reason best explains why adolescents behave in an unsafe manner despite knowledge of a particular activity's risk? Social pressure Normal rebellion Poor judgment Past experience

Social pressure As adolescents explore opportunities, they may know that certain behaviors are unsafe, but social pressure can persuade them to act against their better judgment.

The nurse is reading another nurse's notes that were recorded in the electronic health record (EHR) during the previous shift. What is the appropriate nursing action when numerous unapproved abbreviations are noticed in the previous nurse's notes? Correct the abbreviations in the EHR. Suggest to the nurse manager that an in-service on abbreviation use would be helpful. Ask another nurse to fix the abbreviations. Contact the facility's information technology department to delete abbreviations.

Suggest to the nurse manager that an in-service on abbreviation use would be helpful. Many abbreviations and symbols are not permitted for use in healthcare records. The nurse should never alter documentation, nor it is appropriate to ask another nurse, nor the IT department, to do so. The nurse should talk to the nurse manager about an in-service on appropriate abbreviation use.

The nurse is caring for an 80-year-old client who was admitted to the hospital in a confused and dehydrated state. After the client got out of bed and fell, restraints were applied. She began to fight and was rapidly becoming exhausted. She has black-and-blue marks on her wrists from the restraints. What would be the most appropriate nursing intervention for this client? Leave the restraints on and talk with her, explaining that she must calm down. Talk with the client's family about taking her home because she is out of control. Take the restraints off, stay with her, and talk gently to her. Sedate her with sleeping pills and leave the restraints on.

Take the restraints off, stay with her, and talk gently to her. Physical restraints increase the possibility of the occurrence of falls, skin breakdown and contractures, incontinence, depression, delirium, anxiety, aspiration respiratory difficulties, and even death. The best action in this situation is for the nurse to remove the restraint, stay with the client and gently talk to her. Sedating her with sleeping pills is a chemical form of restraint. Leaving the restraints on the client to talk to her is going to cause further agitation and bruising of her wrists. The client's condition—not confusion and agitation—dictates when the client is discharged.

A client who is enrolled in Medicare and who has been recovering in the hospital from a stroke has developed a pressure injury on his coccyx, an event that the Centers for Medicare & Medicaid Services (CMS) has identified as a "never event." The nurse should recognize what implication of this CMS designation? CMS will bear the hospital's costs if the client chooses to sue the hospital. CMS may choose to divert clients to other health care facilities in the future. The hospital must bear any costs incurred for treating the client's injury. The hospital will be fined by CMS because the client developed a pressure injury.

The hospital must bear any costs incurred for treating the client's injury. If 'never events' occur while a client is hospitalized, the cost of the care associated with that event will not be paid by CMS, but will be borne by the hospital. Fines are not levied against the hospital, however, and CMS does not actively divert clients to other facilities. CMS does not pay damages on behalf of hospitals.

The school nurse is preparing a presentation about safety promotion for middle school students. Which topic should the nurse plan to include? The importance of consistent seat belt use Avoiding workplace injury The importance of practicing moderation when consuming alcohol Identification of hazards associated with falls

The importance of consistent seat belt use Seat belt use is an important safety precaution to teach audiences of all ages. Improper seat belt use (or lack of seat belt use) increases the risk for injury. It is not appropriate to teach middle school children about moderation with alcohol, workplace injury, or falls.

A nurse is preparing to file a safety event report after a client experienced a fall. Which statement is correct regarding the filing of a safety event report? The nurse should record the incident in the client's medical record and fill out a safety event report separately. The nurse should await results of the x-ray before filing the report. The nurse should include a note on the client's chart that mentions the report. The nurse should make a copy of the safety event report and place it in the client's medical record.

The nurse should record the incident in the client's medical record and fill out a safety event report separately. The nurse completes the safety event report immediately after an unintentional injury and is responsible for recording the incident and its effect on the client in the medical record. The safety event report is not a part of the medical record and should not be mentioned in the documentation. The nurse should not wait until after the x-ray to complete the form.

A nurse was injured when a client with Alzheimer's disease struck the nurse on the side of the head during a transfer. The nurse has completed an incident report. Which statement about an incident report is most accurate? The client and the client's family will be required to sign the report, acknowledging that they read it before it was filed. The report provides a detailed and objective account of the circumstances before, during, and after the event. The report becomes a confidential part of the client's health record once it is reviewed by hospital administration. The incident report is reviewed by state agencies and the Occupational Safety and Health Administration rather than by hospital administration.

The report provides a detailed and objective account of the circumstances before, during, and after the event. Incident reports are used for internal review and improvements to systems. They include detailed descriptions of the event in question. They do not become part of the client's health record. They are often provided to outside agencies, but they do not bypass the institution where the event occurred. Clients and their families do not sign incident reports.

A staff development nurse is providing an in-service to a group of nurses on the use of restraints in health care facilities. What is an example of a chemical restraint? side rails a dose of an analgesic a geriatric chair with a tray a dose of an antipsychotic

a dose of an antipsychotic Drugs that are used to control behavior and are not included in the person's normal medical regimen can be considered a chemical restraint. Side rails and a geriatric chair with a tray are examples of physical restraints. Analgesics address pain and are not a restraint.

The nurse is caring for a client who has been repetitively pulled at IV lines and the urinary catheter. After other methods of diverting the client's behaviors fail, the healthcare provider orders chemical restraints. Which treatment does the nurse anticipate? administration of an antipsychotic agent to alter the client's behavior articulating the reason for use of a physical restrictive device to the client's spouse asking the unlicensed assistive personnel (UAP) to sit with the client application of devices that reduce the client's ability to move arms

administration of an antipsychotic agent to alter the client's behavior Chemical restraints are medications, such as an antipsychotic, that are used to manage a client's behavior or freedom of movement. These are generally used to manage violent or self-destructive behavior that jeopardizes the immediate physical safety of the client, staff, or others. Physical restraints are devices that immobilize or reduce the ability of a client to freely move his or her arms, legs, body, or head. Asking the UAP to sit with the client is a diversion method. Articulation of rationale for using a physical restraint is part of nursing teaching.

The nurse recognizes that assessment for sensory-perceptual alterations is a priority for which client? a 12-year-old male who sprained his wrist skateboarding a 16-year-old pregnant female who has morning sickness a 42-year-old female who is a single mom with a sick child home from school an 84-year-old male with four recent driving violations

an 84-year-old male with four recent driving violations An older adult with multiple driving infractions may be having difficulty with sensory-perceptual alterations due to aging changes such as glaucoma, cataracts, presbyopia, presbycusis, cognition, or response time impairments. The 12-year-old should not experience sensory issues with a sprain of the wrist. The 42-year-old may be stressed but is not experiencing illness. The 16-year-old is experiencing illness, but it is not a sensory-perceptual alteration.

A nurse visits an older adult client at home and assesses the safety of the client's environment. Which article can be a threat to the client's safety? carpet on the floor of the living room a laundry bag at the corner of the room skid-resistant small area rugs on the floor area rugs kept on the stairs without carpet

area rugs kept on the stairs without carpet The area rugs kept on the stairs are a health hazard and may cause falls. The older adult client should remove the area rugs from the stairs to prevent accidental injury. Laundry bags, skid-resistant small area rugs, and carpets are not harmful.

An 17-year-old is brought to the emergency department with a head injury. The nurse knows that adolescents are vulnerable to injuries related to: falls from beds. automobile accidents. falls from staircases. play-related injuries.

automobile accidents. Adolescents are prone to injuries related to activities that involve high risk, such as driving. Adolescents tend to be impulsive and take unnecessary risks as a result of peer pressure. Falling from the bed is common in infants. Play-related injuries are commonly seen in school-age children, and falling from staircases is a common injury among toddlers.

An administrative assistant at a large factory visits the medical unit and tells the nurse she is having pain in the right wrist, numbness in the index finger, and decreased mobility of the right hand. The nurse suspects the client has: a fracture of the hand. an infection in the bone. carpal tunnel syndrome. a herniated cervical disc.

carpal tunnel syndrome. Adults with jobs that require repetitive movement (typists, assembly line workers, supermarket checkers, computer operators) may develop carpal tunnel syndrome, a compression of the median nerve that causes pain and decreases hand mobility. A fracture would most likely be accompanied by symptoms including pain, swelling, and an inability to use the extremity. A herniated cervical disk would likely be accompanied by symptoms involving numbness and discomfort of the neck and arms. There are no manifestations consistent with an infection in the bone.

During discharge planning, the nurse is assessing home safety for a client who has repeatedly fallen. Which condition increases the client's risk for falls? Select all that apply. uses non-skid socks all day prefers to use the bathtub when taking a bath takes a diuretic pill early in the morning climbs two flights of stairway to get to his bedroom drinks 2 shots of alcoholic beverages before dinner

climbs two flights of stairway to get to his bedroom prefers to use the bathtub when taking a bath drinks 2 shots of alcoholic beverages before dinner takes a diuretic pill early in the morning Unintentional injuries at home are common for the older adult. Safety habits, no longer reinforced by watchful adults, can become rusty; disregard of judgment, overconfidence, or ignorance can place adults in danger's path. In addition, adults may consume alcohol, which interferes with judgment to interpret the environment and with physical capabilities to operate machinery, thus contributing to injuries.

The residential home nurse is caring for a client who lives in an assisted living unit. In designing a plan of care to prevent fires, the nurse identifies which as the highest risk to the client? clothes dryer cigarette smoking gas stove electrical sockets

gas stove Fire, injury from fire, and fire-related deaths all decreased significantly between 2004 and 2013. Based on data collected by the United States Fire Administration (USFA; 2013), residential fires (31.7%) are second in prevalence only to outdoor fires (39.3%). It is important to note that 80% of all fire deaths occur in the home (Warmack, Wolf, & Frank, 2015). Cooking is the cause of fire in 29.3% of residential cases; some of the other causes include carelessness (9.2%), heating (9%), electrical malfunction (7.9%), appliances (5%), and smoking (2.3%; USFA).

When educating families on fire safety, it is important to: keep a fire extinguisher in a closet. account for all members and then exit. have a meeting place outside the home. use extension cords to prevent shock.

have a meeting place outside the home. The whole family should regularly practice crawling on the floor, using escape routes, and having a meeting place outside the home in case of fire. Attempting to account for all family members before exiting the burning structure is dangerous and may result in the loss of life. Shock is possible with extension cords. Having a fire extinguisher is important but it should be kept in a area with access and not a closet.

The nurses on a critical care unit can utilize the safety strategy of redundancy by: introducing a brief waiting period between the time that a medication is ordered and the time that it is administered. having two nurses independently check the dosage of high-risk medications. ensuring the antidotes are readily available for certain high-risk medications. introducing equipment that makes it more difficult for a nurse to commit an error.

having two nurses independently check the dosage of high-risk medications. Successive checks for certain high risk procedures or events add needed safety redundancy. For example, two registered nurses check the information about the client, and about a blood product about to be administered, to ensure the blood product is the correct one and is safe for the client. The use of antidotes and waiting periods is unrelated to redundancy. Equipment that makes it difficult to commit an error is an example of mistake-proofing.

The nurse is caring for a client who has been repetitively pulled at IV lines and the urinary catheter. After other methods of diverting the client's behaviors fail to prevent this behavior, and chemical restraints fail, which treatment does the nurse anticipate will be ordered? temporary application of devices that reduce the client's ability to move arms delegating to the unlicensed assistive personnel (UAP) to sit with the client providing a sleep agent to help the client rest instead of pulling IV lines and the catheter administration of an antipsychotic agent to alter the client's behavio

temporary application of devices that reduce the client's ability to move arms If diversion behaviors and chemical (drug) restraints have failed, the nurse anticipates that the provider may order temporary application of devices to reduce the client's ability to move arms, which will prevent the behavior. The other actions are not appropriate, so the nurse would not anticipate them.