Ch Safety, Security, Emergency Preparedness
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? A. Initiate use of a bed alarm. B. Administer the client's sedative as ordered. C. Put up all four side rails on the bed. D. Contact the physician for a restraint order.
A. Initiate use of a bed alarm.
A 17-year-old is brought to the emergency department with a head injury. The nurse knows that adolescents are vulnerable to injuries related to:
Automobile accidents
The community health nurse is talking with four clients. Who does the nurse identify that would most benefit from teaching about alcohol and drug use? A. 25-year-old female who just accepted her first job B. 19-year-old male college student majoring in physics C. 34-year-old male who does not use a seat belt D. 40-year-old female who is working two jobs
B. 19-year-old male college student majoring in physics
The nurse has completed a comprehensive assessment of a client who has been admitted to the hospital experiencing acute withdrawal from alcohol. What nursing diagnosis would provide the clearest justification for the use of physical restraints during this client's care?
Risk for Injury Related to Agitation
A nurse is completing an intake assessment. The nurse notes that an older adult male client appears to have bruises in varying stages of healing. Which action by the nurse indicates an understanding of her responsibilities?
The nurse should question the client about the source of the bruises.
