PrepU Chapter 28: Safety, Security, and Emergency Preparedness

The nurse is performing an assessment on an older adult. From which data does the nurse deduce that the client is at high risk for falls in the home? Select all that apply. Takes furosemide daily Admits to drinking wine through the evening Has history of diabetic neuropathy

-Takes furosemide daily -Admits to drinking wine through the evening -Has history of diabetic neuropathy

The nurse is preparing to apply prescribed extremity restraints to a client's ankles. Place in order the steps of the procedure the nurse should perform. Use all options. 1 Pad bony prominences 2 Explain rationale for use to the client and family 3 Secure restraints to the bed frame with quick release knots. 4 Ensure that two fingers fit between the restraint and the client's skin. 5 Position limbs in normal anatomic position. 6 Wrap the restraint around the client's ankle and secure it with hook-and-loop fastener straps.

1.) Explain rationale for use to the client and family (2) 2.) Pad bony prominences (1) 3.) Wrap the restraint around the client's ankle and secure it with hook-and-loop fastener straps. (6) 4.) Ensure that two fingers fit between the restraint and the client's skin. (4) 5.) Position limbs in normal anatomic position. (5) 6.) Secure restraints to the bed frame with quick release knots. (3)

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? 34-year-old male who does not use a seat belt 40-year-old female who is working two jobs 19-year-old male college student majoring in physics 25-year-old female who just accepted her first job

19-year-old male college student majoring in physics

The nurse is providing safety teaching to the family of an older adult client. Which finding in the client's home will the nurse teach the family to address?

Correct response: A hair dryer is placed next to the sink.

The nurse notes that the temperature of an ill client is 101°F (38.3°C). Which intervention would the nurse take to regulate the client's body temperature?

Give the client a bath in tepid water.

A school nurse is aware of poisoning risks in the adolescent population. Poisoning in this age group is most often related to:

experimentation with drugs and inhalants.

A school nurse is aware of poisoning risks in the adolescent population. Poisoning in this age group is most often related to: exposure to toxic fumes in the home. -experimentation with drugs and inhalants. -the ingestion of substances in the home that contain lead. -malfunction of a carbon monoxide monitor in the home.

experimentation with drugs and inhalants.

Which topic should a public health nurse emphasize when educating older adults on reducing their risk of poisoning?

keeping medications in clearly labeled containers

The nurse is teaching an unlicensed assistive personnel (UAP) about fire safety. Which UAP statement demonstrates that teaching has been effective?

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

The poison control nurse receives a call from the parent of a 2-year-old child. The parent states, "I just took a quick shower, and when I finished, I walked into the kitchen and found my child with an open bottle of household cleaner." What is the poison control nurse's appropriate response? "Induce vomiting and call 911 right away." "Did you leave the household chemical in reach of your child?" "Is your child breathing at this time?" "You should not have left your child alone while you showered."

"Is your child breathing at this time?"

A client has presented to the emergency department after splashing a chemical in the eyes. When managing the injury, what should be included in the plan of care?

Flush the eyes with water for 10 minutes.

The nurse is teaching the caregiver of an adolescent child about safety. Which teaching will the nurse include?

Peer pressure causes children of this age to take risks.

An older adult is admitted to the hospital with a fractured hip. The client suddenly develops acute onset of confusion and hallucinations. Which action should the nurse implement first?

Reduce distressing environmental stimuli to maximize client safety Explanation: Added stimulation can increase the maladaptive behaviors of the client; therefore, the nurse should first reduce the distressing environmental stimuli. Proper communication of client status change is a legal requirement of nurses, and documentation provides a means of communication between interdisciplinary teams and provides continuing of care. However, notifying the health care provider and documenting the change in status are not the priority action. Restraints are to be used as a last resort in client care.

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.

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? -Chronic Confusion Related to Long-Standing Alcohol Use -Impaired Bed Mobility Related to Muscle Wasting -Risk for Injury Related to Agitation -Noncompliance Related to Medication Regimen

Risk for Injury Related to Agitation

The nurse is caring for a young child in the hospital who is being discharged home with his grandmother, who has guardianship. When performing a risk assessment, the nurse identifies that his grandmother has one other adult living with her to help with the child, because the grandmother has congestive heart failure and diabetes mellitus. In addition, the financial situation is poor and she cannot afford to buy safety devices to safety-proof the house. What nursing diagnosis is most appropriate for this child based on these findings?

Risk for Poisoning related to medications in unlocked cabinets

The nurse is caring for a client who has been prescribed extremity restraints. Which action must be documented by the nurse?

The alternative measures attempted before applying the restraints

A school nurse is conducting a safety seminar with students in 6th grade. Which teaching point is most important?

You Selected: "Make sure that you have smoke detectors in your house and that they're in working order."

Which factor is related to the highest proportion of falls in long-term care settings?

Toileting

The nurse is preparing to discuss safety with a group of parents of infants. When planning the program, which topic would be most important to include?

Use of blankets, pillows, and stuffed animals in the crib Explanation: Infant safety education should include use of approved car seats and not booster seats. Booster seats are used for the pre-school child with recommended height and weight. The use of skid-proof mats in the bathtub are topics more suited to the parents of preschool children. Infants are not likely to be physically able to access guns in the home. Infants should not have pillows, stuffed animals, or blankets in the bed due to the risk of suffocation.

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:

mass trauma terrorism. Explanation: Mass trauma terrorism is caused by bombs and other explosives that are used to inflict mass trauma and cause multiple fatalities. Bioterrorism involves the deliberate spread of pathogenic organisms into the community. Chemical terrorism involves the deliberate release of a chemical compound for the purpose of causing mass destruction. Nuclear terrorism involves the dispersal of radioactive materials into the environment for the purpose of causing injury and death.