Ch. 27

The nurse is assessing an adolescent with an annual physical. The parent reports noticing a change in the child's behavior lately, including mood swings, withdrawal from the family, and failing school grades. The parent does not know what to do and asks the nurse for guidance. What is the most appropriate guidance from the nurse?

"These could be signs of substance use. Open communication and seeing a counselor who specializes in substance use would be beneficial."

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?

Assessment of vital signs and respiratory status

Which topics should be included in an education plan for preventing falls in the home? Select all that apply.

Avoid climbing on a chair or table to reach items that are too high. Use a nightlight. Remove clutter from walkways. Keep electrical and telephone cords against the wall and out of walkways. Consider the use of a raised toilet seat.

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?

Avoid stuffed animals and blankets in the crib.

The nurse is able to help promote safety and prevent injury by identifying which factors that have a direct impact on client safety? Select all that apply.

Communication ability Developmental level Mobility

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.

Drowsiness Headache Vomiting

The nurse is caring for an adult who requires IV fluids but continues to pull at the IV site and tubing. The adult child tries to calm the client, without success. Which short-term restraints should the nurse use to control the adult's movement during the procedure?

Extremity restraint

When educating families on fire safety in the home, which information is important for the nurse to emphasize?

Have a meeting place outside the home in case of fire.

A nurse is volunteering in a free community health clinic. One of the services offered is vehicle restraint checks for children. Which principles apply to infant and child restraints? Select all that apply.

Infants should be rear-facing up to the age of 2 years. Booster seats should be used until the child is 4 ft 9 in (145 cm) tall.

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?

Refrain from using extension cords.

The nurse on a medical-surgical unit notices smoke from a client's room. Upon entering, the nurse notes that the curtain in the room is on fire. What should be the nurse's first action?

Remove the client from the room.

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?

Take the restraints off, stay with her, and talk gently to her.

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

What is the best short-term outcome for a client with the nursing diagnosis of Risk for Injury related to risk-taking behaviors?

The client will identify behaviors that would decrease the risk for injury.

A client who is enrolled in Medicare and who has been recovering in the hospital from a stroke has developed a pressure injury on the 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?

The hospital must bear any costs incurred for treating the client's injury.

A nurse is using the QSEN competency of evidence-based practice when caring for clients. What is an example of this competency?

The nurse researches best current practices for prevention of the spread of infection in physician offices.

The nurse uses the QSEN competency of Informatics when planning care for clients. What is an example of the use of this skill?

The nurse researches new technological advances in the treatment of cancer.

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.

Which actions should the nurse perform to help prevent occupational safety hazards? Select all that apply.

Use equipment only for the use for which it was intended. Only operate equipment the nurse is familiar with. Use three-pronged electric plugs whenever possible.

The nurse recognizes that assessment for sensory-perceptual alterations is a priority for which client?

an 84-year-old male with four recent driving violations

A near miss has taken place on a medical unit in which a client nearly received a unit of packed red blood cells of an incompatible blood type. In the follow up to this event, which action should be prioritized?

identifying systemic factors on the unit that may have contributed to the event

Which clients are most at risk for falling due to altered mobility? Select all that apply.

A client with a spinal cord injury An older adult client with an unsteady gait A client who requires crutches in unfamiliar health care settings

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?

Initiate use of a bed alarm.

A hospital is introducing a program that has the goal of aligning practices more closely with the Quality and Safety Education for Nurses (QSEN) project. What initiative best exemplifies QSEN competencies?

New systems are introduced to increase communication between nurses and the members of other health disciplines.

The nurse is caring for a school-age child and notices a variety of circular burns on the back and legs in various stages of healing. What action should the nurse take related to this suspicion?

Notify the National Abuse Hotline.

A nurse is teaching parents about Internet safety for children. Which actions are recommended guidelines for Internet use? Select all that apply.

Use filtering software to block objectionable information. Investigate any public chat rooms used by the children. Be alert for downloaded files with suffixes that indicate images or pictures.

The nurse is caring for a client who has been repetitively pulling at IV lines and the urinary catheter. After other methods of diverting the client's behaviors fail, the health care provider orders chemical restraints. Which treatment does the nurse anticipate?

administration of an antipsychotic agent to alter the client's behavior