NU140- Chapter 27 Safety, Security, and Emergency Preparedness

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 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?

"Is your child breathing at this time?"

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 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."

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?

19-year-old male college student majoring in physics

Which nurse would be at the highest risk of causing a hazardous situation?

A nurse who has worked 32 hours of overtime this week

The acronym RACE is commonly taught as a means for remembering priorities for action during a fire. The "A" in this acronym stands for which of the following?

Activate the fire alarm and notify the appropriate person.

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?

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

A health care provider orders extremity restraints for a confused client who is at risk for injury by pulling out her central venous catheter. What is the nurse's most appropriate action when carrying out this order?

Ensure that two fingers can be inserted between the restraint and the client's extremity.

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

A home care nurse provides health education to parents regarding the care of their toddler. Which precaution should the nurse suggest the parents take to protect the toddler from drowning?

Avoid unattended baths for the toddler.

The older adult client is moving to another apartment. The nurse should encourage the client's family to take which action to reduce the older adult's risk of falling in the new home?

Clear clutter in the walkways of the new home.

A confused client is pulling at the IV line. When considering alternatives to restraints, which nursing intervention would be used first?

Conceal IV tubing with gauze wrap

Which item would alert the home care nurse to a safety hazard threatening a young child?

Dangling blind cords

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.

One of the leading causes of death in the United States is drowning. How can the nurse assist in lowering this statistic?

Implement drowning prevention strategies.

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.

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 people who die in house fires die of smoke inhalation rather than burns.

What best describes the nurse's role in disaster preparedness?

Multiple roles, including triage and the distribution of resources

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?

Obtain a three-prong grounded plug adapter.

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?

Placing the client in a bed with a bed alarm

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

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.

An older adult client has developed diabetic neuropathy. What would be the most important education intervention for the client and family?

Reduce the temperature on the water heater.

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.

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?

Restrain the baby in a car seat.

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

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 Poisoning related to poor eyesight and the inability to read medication labels

Which reason best explains why adolescents behave in an unsafe manner despite knowledge of a particular activity's risk?

Social pressure

The nurse is teaching the caregiver of a 8-month-old infant about safety. Which teaching will the nurse include?

Supervise your child on the changing table.

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 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 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 filing a safety event report for an older adult client who tripped and fell when getting out of bed. Which action exemplifies an accurate step of this process?

The nurse details the client's response and the examination and treatment of the client after the incident.

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.

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.

A nurse is preparing to implement an order for the use of restraints to ensure a client's safety. Which statement accurately describes a guideline to follow?

Time-limit the use of restraints and release the client from the restraint as soon as he or she is no longer a risk to self or others.

The nurse performs discharge teaching for the family of an older adult client with a visual impairment and decreased mobility. Which instruction would the nurse give to help prevent falls in the client's home?

Use night-lights in bedrooms and bathrooms.

A nurse is assessing the following children. Which child would the nurse identify as having the greatest risk for choking and suffocating? a. A toddler playing with his 9-year-old brother's construction set b. A 4-year-old eating yogurt for lunch c. An infant covered with a small blanket and asleep in the crib d. A 3-year-old drinking a glass of juice

a. A toddler playing with his 9-year-old brother's construction set

A nurse is teaching parents in a parenting class about the use of car seats and restraints for infants and children. Which information is accurate and should be included in the teaching plan? a. Booster seats should be used for children until they are 4′9″ tall and weigh between 80 and 100 lb. b. Most U.S. states mandate the use of infant car seats and carriers when transporting a child in a motor vehicle. c. Infants and toddlers up to 2 years of age (or up to the maximum height and weight for the seat) should be in a front-facing safety seat. d. Children older than 6 years may be restrained using a car seat belt in the back seat.

a. Booster seats should be used for children until they are 4'9" tall and weigh between 80 and 100 lb.

When a fire occurs in a patient's room, what would be the nurse's priority action? a. Rescue the patient. b. Extinguish the fire. c. Sound the alarm. d. Run for help.

a. Rescue the patient.

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

A 5-year-old is admitted to the ICU after a head trauma from a bike injury. The child is awake but confused, and continues to pull at IV tubing and a catheter. When the provider orders a restraint, what options would be least restrictive? Select all that apply.

administration of sedation four side rails up having a parent stay with the child

Disaster

an emergency event of greater magnitude that requires the response of people outside the involved community

Sentinel event

an unexpected occurrence involving death or serious physical or psychological injury, or the risk thereof

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 nurse caring for patients in a long-term care facility knows that there are factors that place certain patients at a higher risk for falls. Which patients would the nurse consider to be in this category? Select all that apply. a. A patient who is older than 50 b. A patient who has already fallen twice c. A patient who is taking antibiotics d. A patient who experiences postural hypotension e. A patient who is experiencing nausea from chemotherapy f. A 70-year-old patient who is transferred to long-term care

b. A patient who has already fallen twice d. A patient who experiences postural hypotension f. A 70-year-old patient who is transferred to long-term care

The Joint Commission issues guidelines regarding the use of restraints. In which case is a restraint properly used? a. The nurse positions a patient in a supine position prior to applying wrist restraints. b. The nurse ensures that two fingers can be inserted between the restraint and patient's ankle. c. The nurse applies a cloth restraint to the left hand of a patient with an IV catheter in the right wrist. d. The nurse ties an elbow restraint to the raised side rail of a patient's bed.

b. The nurse ensures that two fingers can be inserted between the restraint and the patient's ankle.

A school nurse is teaching parents about home safety and fires. What information would be accurate to include in the teaching plan? Select all that apply. a. Sixty percent of U.S. fire deaths occur in the home. b. Most fatal fires occur when people are cooking. c. Most people who die in fires die of smoke inhalation. d. Fire-related injury and death have declined due to the availability and use of smoke alarms. e. Fires are more likely to occur in homes without electricity or gas. f. Fires are less likely to spread if bedroom doors are kept open when sleeping.

c. Most people who die in fires die of smoke inhalation d. Fire-related injury and death have declined due to the availability and use of smoke alarms e. Fires are more likely to occur in homes without electricity or gas

While discussing home safety with the nurse, a patient admits that she always smokes a cigarette in bed before falling asleep at night. Which nursing diagnosis would be the priority for this patient? a. Impaired gas exchange related to cigarette smoking b. Anxiety related to inability to stop smoking c. Risk for suffocation related to unfamiliarity with fire prevention guidelines d. Deficient knowledge related to lack of follow-through of recommendation to stop smoking

c. Risk for suffocation related to unfamiliarity with fire prevention guidelines

What consideration should the nurse keep in mind regarding the use of side rails for a patient who is confused? a. They prevent confused patients from wandering. b. A history of a previous fall from a bed with raised side rails is insignificant. c. Alternative measures are ineffective to prevent wandering. d. A person of small stature is at increased risk for injury from entrapment.

d. A person of small stature is at increased risk for injury from entrapment.

When discussing emergency preparedness with a group of first responders, what information would be important to include about preparation for a terrorist attack? a. Posttraumatic stress disorders can be expected in most survivors of a terrorist attack. b. The FDA has collaborated with drug companies to create stockpiles of emergency drugs. c. Even small doses of radiation result in bone marrow depression and cancer. d. BLI is a serious consequence following detonation of an explosive device.

d. BLI is a serious consequence following detonation of an explosive device.

A nurse working in a pediatrician's office receives calls from parents whose children have ingested toxins. What would be the nurse's best response? a. Administer activated charcoal in tablet form and take child to the ED. b. Administer syrup of ipecac and take child to the ED. c. Bring the child in to the primary care provider for gastric lavage. d. Call the PCC immediately before attempting any home remedy.

d. Call the PCC immediately before attempting any home remedy.

A nurse orients an older adult to the safety features in her hospital room. What is a priority component of this admission routine? a. Explain how to use the telephone. b. Introduce the patient to her roommate. c. Review the hospital policy on visiting hours. d. Explain how to operate the call bell.

d. Explain how to operate the call bell.

An older resident who is disoriented likes to wander the halls of his long-term care facility. Which action would be most appropriate for the nurse to use as an alternative to restraints? a. Sitting him in a geriatric chair near the nurses' station b. Using the sheets to secure him snugly in his bed c. Keeping the bed in the high position d. Identifying his door with his picture and a balloon

d. Identifying his door with his picture and a balloon

Based on the statistics for the leading cause of hospital admission for trauma in older adults, what would be the nurse's priority intervention to prevent trauma when caring for older adults in a nursing home? a. Checking to make sure fire alarms are working properly. b. Preventing exposure to temperature extremes. c. Screening for partner or elder abuse. d. Making sure patient rooms are decluttered.

d. Making sure patient rooms are decluttered

A nurse is filing a safety event report for a confused patient who fell when getting out of bed. What action is performed appropriately? a. The nurse includes suggestions on how to prevent the incident from recurring. b. The nurse provides minimal information about the incident. c. The nurse discusses the details with the patient before documenting them. d. The nurse records the circumstances and effect on the patient in the medical record.

d. The nurse records the circumstances and effect on the patient in the medical record.

Restraint

device used to limit movement or immobilize a patient

Safety event report

documentation describing any injury or potential for injury suffered by a patient in a health care facility

Intimate partner violence (IPV)

domestic violence or battering between two people in a close relationship

Chemical emergency

event caused by the release of a chemical compound that has the potential for harming people's health

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.

Poison control center

facility that handles poison exposure and provides poison prevention teaching to the general population

When educating families on fire safety, it is important to:

have a meeting place outside the home.

Elder abuse

intentional act or failure to act by a caregiver or another person in a relationship involving an expectation of trust that causes or creates a risk of harm to an older adult; includes physical abuse, sexual abuse/contact, emotional/psychological abuse, neglect, and financial abuse/exploitation

Nuclear terrorism

intentional dispersal of radioactive materials into the environment for the purpose of causing injury and death

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.

Bullying

negative, often repetitive, disruptive behavior; also referred to as horizontal violence, lateral violence, and professional incivility

Culture of safety

organizational environment where "core values and behaviors resulting from a collective and sustained commitment by organizational leadership, management, and workers emphasize safety over competing goals"

Which action by the unlicensed assistive personnel (UAP) requires intervention from the nurse when providing care to an older adult client who is at risk for falls?

provides slippers for ambulation

Asphyxiation

stoppage of breathing or the lack of air reaching the lungs; synonym for suffocation

The nurse is working at a local elementary school. A mother arrives to pick up her 6-year-old son and has her 2-year-old daughter in tow. Based on the nurse's developmental knowledge of toddlers, which behavior would most concern the nurse?

the 2-year-old leaning against the screen of a window in a classroom

Bioterrorism

the deliberate spread of pathogenic organisms into a community to cause widespread illness, fear, and panic

Cyber terror

the use of high-tech means to disable or delete critical electronic infrastructure data or information