Chapter 27: Safety, Security, and Emergency Preparedness

When performing fall risk assessments, which client does the nurse determine is most at risk for falls? A 70-year-old female with postural hypotension who wears eyeglasses, but has no history of falls An 80-year-old female with a history of falling last year and breaking a hip A 60-year-old male with weakness in his left side and slowed reaction time A 50-year-old male being cared for in an unfamiliar health care environment

A 70-year-old female with postural hypotension who wears eyeglasses, but has no history of falls

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? Nothing, as it is none of the nurse's concern. Document the observed behaviors in the client's chart. Ask to examine the client alone in order to speak to her privately. Report the suspicions to to the authorities.

Ask to examine the client alone in order to speak to her privately. In 90% of elder abuse cases that are reported, the person doing the abusing is a family member. The best thing to do would be for the nurse to get the client alone so that she can discuss the relationship that was observed. Documenting the behaviors is appropriate, but not enough. More assessment is needed to prevent possible injury to the client. The nurse must address what could be a sign of elder abuse, and reporting it to authorities may be appropriate after more assessment and following protocols.

The nurse is caring for an older adult client who states the need to use the restroom. Which safety intervention must the nurse perform first? Arrange furniture so that the client has something to hold on to. Assess the need for assistance with ambulation. Put the client's bedside rails up. Apply socks to the client's feet.

Assess the need for assistance with ambulation. The diverse physiologic and psychologic capabilities of people and encounters with various safety hazards across the lifespan put various age groups at risk for different safety concerns and potential injuries. Older adult clients are at a higher risk for falling. Thus, the nurse should assess the client's ability to ambulate independently before allowing the client to go to the restroom and to provide assistance, if needed. The nurse would lower, not raise, the bedside rails before having the client exit the bed. The nurse would put nonskid footwear like slippers, not socks, on the client to help prevent falls. Furniture should be arranged so that the client has a clear and easy path to the restroom. 778

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. Flush the eyes with a cool saline solution for a 10-minute period. Advise the client to avoid blinking until after the eyes are irrigated. Wash the eyes with a hypertonic solution for at least 30 minutes.

Flush the eyes with water for 10 minutes. If poisonous substances have been instilled into the eye, immediate irrigation with lukewarm water for 10 to 15 minutes may reduce harmful effects. 780

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. Community population Type of health care facility Mobility Communication ability Developmental level

Mobility Communication ability Developmental level Nurses should be stewards of a safe environment. In order to promote safety and prevent injuries, nurses must be aware of factors that impact the safety of clients. Some of those factors include the client's developmental level, lifestyle, mobility, sensory perception, knowledge level, communication ability, physical health state, and psychosocial state. The community's population and the type of facility that the client is in should not impact the safety of the client. 752

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

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? Use an extension cord to provide freedom of movement. Obtain a three-prong grounded plug adapter. Tape the electrical cord of the pump to the floor. Run the electrical cord of the pump under the carpet.

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. 777

What are the six competencies in the QSEN?

Patient-Centered Care Teamwork and Collaboration Evidence-Based Practice Quality Improvement Safety Informatics

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

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. p. 771

A client on a hospital unit has been infected with hepatitis C virus (HCV) because a nurse mistakenly connected the client with an HCV-positive client's intravenous pump and tubing. What is an appropriate response by the hospital to this incident? Offer compensation to the affected client in a timely manner, while maintaining the client's confidentiality. File an incident report with the American Nurses Association describing plans for preventing similar events in the future. Report this sentinel event to the Joint Commission and to relevant state agencies Inform the public that the incident occurred, while protecting the confidentiality of the clients.

Report this sentinel event to the Joint Commission and to relevant state agencies At issue here is that the nurse directly exposed a client via direct bloodline to a client infected with HCV. The uninfected client could become infected and require lengthy treatment. Sentinel events must be reported to the Joint Commission and to relevant state agencies. Sentinel events are not normally publicized, and incident reports are not provided to the ANA. Matters related to financial compensation would likely involve the courts, not the Joint Commission or health agencies.

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? Sedate her with sleeping pills and leave the restraints on. Talk with the client's family about taking her home because she is out of control. Leave the restraints on and talk with her, explaining that she must calm down. Take the restraints off, stay with her, and talk gently to her.

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. 774-775

The nurse is caring for a client who has been prescribed extremity restraints. Which action must be documented by the nurse? The type of personal protective equipment used by the nurse during restraint application The alternative measures attempted before applying the restraints A verbal prescription for the restraints, renewed every 48 hours A detailed description of the restraint application process

The alternative measures attempted before applying the restraints Reasonable measures to avoid the use of restraints must be attempted before implementation; these measures must be documented. Verbal restraint prescriptions must be renewed every 24 hours, not every 48 hours. Neither a detailed description of the restraint application process nor the type of personal protective equipment used by the nurse during restraint application are required to be documented. 786-789

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 notify the primary care physician about the bruises. The nurse should request permission from the client to photograph the bruises. The nurse should question the client about the source of the bruises. The nurse should contact the facility's social services department.

The nurse should question the client about the source of the bruises. The initial action by the nurse would be to determine the source of the bruises. If suspicion remains, the nurse should question the client. If the nurse feels there is potential abuse the nurse is obligated to report it. 767

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 Increased thirst Fever Headache Drowsiness

Vomiting, drowsiness, headeache Concussions are a frequently seen sports injury in school-age children. Nurses should be aware of symptoms that may indicate that a concussion or more serious head injury is present. Symptoms of a concussion include headache, vomiting, problems with balance, fatigue, dazed or stunned appearance, difficulty concentrating and remembering, confusion, forgetfulness, irritability, nervousness, very emotional behavior, drowsiness, difficulty falling asleep, and sleeping more or less than usual. Fever and increased thirst are not symptoms usually seen with a concussion. 768

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? a dose of an antipsychotic side rails a dose of an analgesic a geriatric chair with a tray

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. 775

sentinel event

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

safety event report

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

chemical emergency?

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

poison control center:

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

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

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"

Analgesics, antihistamines, and ______________ are the drugs most often implicated in poisoning deaths in young children.

sedatives

asphyxiation?

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

cyber terror

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

intimate partner violence (IPV)

violence that occurs between individuals who maintain a romantic or sexual relationship