Safety, Infection Control, Culture & Diversity

What are techniques and behaviors that reflect cultural sensitivity?

-Always address clients by their last name till they give you permission to use other names -When meeting people for the first time, introduce yourself by name, and then explain your role -Be authentic and honest with people about the knowledge you lack about their culture -Use language that is culturally sensitive -Find out what the client thinks about his or her health problems, illness, and treatments -Do not make any assumptions about the client and always ask about anything you do not understand -Show respect for the client's values, beliefs, and practices, even if they differ from your own -Show respect for the client's support people

Use the nursing process to plan care for issues in safety for adults.

-Identify environmental hazards in the home and community -Demonstrate safety practices, appropriate to the home health care agency, community, and workplace -Experience a decrease in the frequency or severity of injury -Demonstrate safe child-rearing practices or lifestyle practices -Describe methods to prevent specific hazards -Report use of home safety measures -Alter home physical environment to reduce the risk of injury - Describe emergency procedures for poisoning and fire - Describe age specific risks, work safety risks, or community safety risks -Demonstrate correct use of child safety seats - Demonstrate correct administration of cardiopulmonary resuscitation

When using the Risk for Infection label the nurse should identify risk factors like:

-Inadequate primary defenses: such as broken skin, traumatized tissue; decreased ciliary action, stasis of body fluids, change in pH of secretions, or altered peristalsis -Inadequate secondary defenses: such as leukopenia, immunosuppression, decreased hemoglobin, or suppressed inflammatory response

What are examples of nursing diagnoses that may arise from the actual presence of an infection?

-Potential Complication of Infection: Fever -Imbalanced Nutrition: Less Than Body Requirements (if the client is too ill to eat adequately) - Acute Pain: if the client is experiencing tissue damage and discomfort - Impaired Social Interaction or Social Isolation: if the client is required to be separated from others during a contagious episode - Anxiety: if the client is apprehensive regarding changes in life activities resulting from the infection or its treatment such as absence from work or inability to perform usual functions

What does the nurse assess for when assessing for infection?

-Respiratory: cough, congestion, runny nose, sore throat, chest pain -Gastrointestinal: nausea, vomiting, diarrhea, cramping, anorexia -Genitourinary: voiding urgency, frequency, burning, flank pain, foul odor, discharge -Wound: inflammation, redness, swelling, heat, drainage, pain -General: fever, elevated WBC's, positive cultures -Geriatric alert: may not become febrile may have behavioral changes instead chronic degenerative changes may mask symptoms

What are nursing diagnosis related to issues with infection?

-Risk for Infection: the state in which an individual is at increased risk for being invaded by pathogenic microorganisms

Indicate factors to consider when conducting a cultural assessment.

-Use open-ended questions to obtain more information about: cultural affiliation (cultural heritage) beliefs about current illness health care practices illness beliefs and care practices family life and support system

Factors that can be included in the definition of diversity

-age -race -gender -sexual orientation -physical abilities -ethnicity -marital status -educational background -religion/spirituality -income -geographic location -field of employment

What are the implications of restraints?

-clients can become more restless and anxious as a result of the loss of self-control

What are some interventions to the chain of infection?

-ensuring that articles are correctly cleaned and disinfected or sterilized before use -educate clients & support people about appropriate methods for cleaning, disinfecting, and sterilizing articles -change dressings and bandages when they are soiled or wet -assist clients to carry out appropriate skin and oral hygiene -dispose of damp, soiled linens appropriately -avoid talking, coughing, or sneezing over open wounds or sterile fields, and cover the mouth and nose when coughing or sneezing -cleanse hands between client contacts, after touching body substances, and before performing invasive procedures or touching open wounds -use aseptic technique for invasive procedures -maintain the integrity of the client's skin and mucous membranes

What are potential hazards for a fetus?

-exposure to maternal smoking, alcohol consumption, addictive drugs, x-rays (first trimester), certain pesticides

What emotional states can place people at risk for injury?

-extreme emotional states: alter ability to perceive environmental hazards -stressful situations: reduce level of concentration, cause errors of judgement, decrease awareness of external stimuli -depression: may think and react to environmental stimuli more slowly

What are potential hazards for older adults?

-falling -burns -pedestrian and automobile crashes

What are potential hazards for an infant?

-falling -suffocation in crib -placement in the prone position -suffocation when entangled in cords -choking from aspirated milk or ingested objects -burns from hot water or other spilled hot liquids -automobile crashes -crib or playpen injuries - electric shock -poisoning

How does ones ability to communicate place them at risk for injury?

-if they have aphasia, language barriers, or they cannot read it could hinder their ability to receive and convey information

What are the potential hazards for school age children?

-injury from traffic -playground equipment -choking -suffocation -obstruction of airway or ear canal by foreign objects -poisoning -drowning -fire and burns -harm from other people or animals

What interventions can you implement to prevent falls?

-keep a call light within patient's reach -keeping frequently used items close to the patient -making hourly rounds to check on patients -keeping patients who are at a high risk for falling in rooms close to the nurse's station -ensure brakes are applied on beds -ensure that safety locks are used on wheelchairs -grab bars near a toilet -grab bars in a shower stall

What impaired awareness factors place people at risk for injury?

-lack of sleep -people who are unconscious or semiconscious -people who are disoriented and may not understand where they are or what to do to help themselves -people who perceive stimuli that does not exist -people whose judgement is altered by disease or medications

What are the measures to provide culturally competent care?

-learn the rituals, customs, and practice of the major cultural groups with whom you come in contact with -identify personal biases, attitudes, prejudices, and stereotypes -include cultural assessment of the client and family as part of overall assessment -recognize that it is the client's right to make their own health care choices -convey respect and cooperate with traditional helpers and caregivers

What are the major goals for clients susceptible to infection?

-maintain or restore defenses -avoid the spread of infectious organisms -reduce or alleviate problems associated with the infection

What are some alternatives to restraints?

-orient to surroundings -explain all procedures and treatments -encourage family and friends to stay with client -assign confused and disoriented clients to rooms near nurse's station -provide appropriate visual and auditory stimuli -place familiar items near bedside -maintain toileting routine -eliminate bothersome treatments -evaluate all meds client is receiving -use relaxation techniques -institute ambulation and exercise schedules -assess for pain and adequate pain control

What mobility factors place people at risk for injury?

-paralysis -muscle weakness -diminished balance -lack of coordination

What are potential hazards for toddlers?

-physical trauma from falling -running into objects -aspiration of small toys -getting cut by sharp objects -automobile crashes -burns -poisoning -drowning -electric shock

What are lifestyle factors that place people at risk for injury?

-unsafe work environment -residence in neighborhoods with high crime rates -access to firearms -insufficient income to purchase safety equipment or make necessary repairs -access to illicit drugs

What are potential hazards for adolescents?

-vehicular (automobile, bicycle) crashes -recreational injuries -firearms -substance abuse

What interventions can you implement to prevent injuries during seizures?

-wear a medical identification tag -confirm client's are taking their antiepileptic medications correctly -remain with client during seizure -assist client to floor if not in bed (hold client's head in lap or on pillow -loosen clothing around neck and chest -if possible turn to lateral position -move items in environment to ensure the client does not experience injury -time seizure duration -use equipment to suction oral airway if the client vomits or has excessive oral secretions

What are some factors affecting safety?

1. Age and Development 2. Lifestyle 3. Mobility and health status 4. Sensory-Perceptual Alterations 5. Cognitive Awareness 6. Emotional State 7. Ability to communicate 8. Safety Awareness 9. Environmental Factors

What are the steps you should take to form a plan of care incorporating adaptations to accommodate for the needs of diverse populations?

1. Become aware of one's own cultural heritage 2. Become aware of the client's heritage and health traditions as described by the client 3. Become aware of adaptations the client made to live in another culture. During this part of the interview, a nurse can also identify the client's preferences in health practices, diet, hygiene, and so on. 4. Form a nursing plan with the client that incorporates his or her cultural beliefs regarding the maintenance, protection, and restoration of health. In this way, cultural values, practices, and beliefs can be incorporated with the necessary nursing care

Which nursing action primarily supports restoring HEALTH using traditional methods? 1.) Herbal teas 2.) Prayer 3.) Wearing symbolic objects 4.) Exercise

1. Herbal teas Herbal teas are an example of a restoring health action

What are the rights of access to courts in the patient bill of rights?

1. Involuntary patients can ask a court to review the order placing them in a facility 2. You may sue someone for damages or other court relief if they violate any of your rights 3. Legal services are available at the mental health facilities and secure treatment centers for some court matters. Ask staff how to contact those services. 4. You may also get help from the Disability Rights Wisconsin. They investigate grievances of client abuse or neglect and other rights violations 5. You may call your attorney, patient rights staff or DRW at reasonable times. If you cannot afford such calls, the facility must provide them to you free of charge

What are five characteristic signs of an infection?

1. Pain 2. Swelling 3. Redness 4. Heat 5. Impaired function of the part, if the injury is severe

Which of the following factors are most likely to be influence by culture as opposed to personal characteristics? Select all that apply 1.) Value of older people in society 2.) Gender roles 3.) Nonverbal gestures 4.) Skill with technology 5.) Intelligence 6.) Diet

1. Value of older people in society, 2. Gender Roles, 3. Nonverbal gestures, and 6. Diet

What are the communication and privacy rights in the patient bill of rights?

1. You may use the telephone daily 2. You may see, or refuse to see visitors daily 3. You must have privacy when you are in the bathroom 4. You may wear your own clothing 5. You may keep and use your own belongings 6. You must be given a reasonable amount of secure storage space 7. You must be given the opportunity to have your clothes washed 8. You may send and receive private mail 9. Staff cannot read your mail unless you or your guardian asks them to do so. Staff may check your mail for contraband. 10. You may call or write to public officials or your lawyer or advocate 11. You cannot be filmed or taped unless you agree to it. 12. You may use your own money as you choose, within some limits

What are the treatment rights in the patient bill of rights?

1. You must be provided prompt and adequate treatment, rehabilitation and educational services appropriate for your condition 2. You must be allowed to participate in the planning of your treatment and care. 3. You must be informed of your treatment and care, including alternatives and possible side effects of medication 4. No treatment or med may be given to you without your consent, unless it is needed in an emergency to prevent serious physical harm to you or others, or a court orders it. 5. You must not be given unnecessary or excessive medication 6. You may not be subject to electro-convulsive therapy or any other "drastic treatment measures" such as psychosurgery or experimental research without your consent 7. You must be informed of any costs of care and treatment that you or your relatives may have to pay 8. You may not be restrained or placed in a locked room unless in an emergency when it is necessary to prevent physical harm to you or to others 9. You must be treated in the least restrictive manner and setting necessary to safely and appropriately meet you needs Note: this right does not apply to forensic patients at state mental health institutions

What are the personal rights in the patient bill of rights?

1. You must be treated with dignity and respect free of any verbal or physical abuse 2. Your surroundings must be kept safe and clean 3. You must be given the chance to exercise, go outside for fresh air regularly and frequently and go to off unit recreational facilities when possible 4. You have the right to have staff make fair and reasonable decisions about your treatment and care 5. You can decide whether you want to participate in religious services 6. You cannot be made to work except for personal housekeeping chores. If you agree to do other work, you must be paid 7. If you are an adult, you can make your own decisions about things like getting married, voting and writing a will

What are record privacy and access rights in the patient bill of rights?

1. Your treatment info must be kept confidential. Your records cannot be released without your consent, unless the law specifically allows for it. 2. You can ask to see your records. You must be shown any records about your physical health or medications. Staff may limit how much you can see of the rest of your records, while you are at the facility. You must be informed of the reasons for any such limits. You can challenge those reasons by filing a grievance. After discharge, you can see your entire record if you ask to do so. 3. If you believe something in your records is not correct, you can challenge its accuracy. If staff do not change the part of your records you have challenged, you can insert your own version in your record.

Define principles and components of holistic patient centered care.

1. identify your personal assumptions, biases, attitudes, prejudices, and stereotypes. include cultural assessment of the client and family as part of your overall assessment 2. Learn the rituals, customs, and practices of the major cultural groups with whom you come into contact, recognizing that these generalizations may not hold true at the individual level. Learn to appreciate the richness of diversity and consider it an asset rather than a hinderance in your practice. 3. Don't make assumptions about beliefs or practices 4. Ask about the client's use of cultural or alternative approaches to healing. 5. Recognize that it is the client's (or family's) right to make their own health care choices. Explain in detail the client's condition and the treatment plan if the client is willing for you to do this 6. Convey respect and cooperate with traditional helpers and caregivers

What are the six links in the chain of infection?

1. pathogen (etiologic agent, microorganism) 2. reservoir (place where the organism naturally resides) 3. portal of exit (from the reservoir) 4. means of transmission 5. portal of entry (into the host) 6. new host (susceptible)

What are the nurse's professional responsibilities related to infection transmission?

1. preventing nosocomial infections (using medical & surgical asepsis) 2. hand hygiene 3. supporting defense of a susceptible host (hygiene, nutrition, fluid intake, adequate sleep, decreasing stress, and immunizations) 4. disinfecting and sterilizing 5. infection prevention and control (standard precautions, transmission-based precautions, compromised clients) 6. isolation practices (PPE, disposal of soiled equipment and supplies, bagging, linens, laboratory specimens, dishes, blood pressure equipment, thermometers, disposable needles, transporting clients with infections, psychosocial needs of isolation clients) 7. sterile technique (sterile field, sterile gloves, sterile gowns)

The nurse enters the nursing lounge and discovers that a chair is on fire. The nurse activates the alarm closes the lounge door, and obtains the fire extinguisher to extinguish the fire. The nurse pulls the pin on the fire extinguisher. Which is the next action the nurse should perform? 1.) Aim at the base of the fire 2.) Squeeze the handle on the extinguisher 3.) Sweep the fire from side to side with the extinguisher 4.) Sweep the fire from top to bottom with the extinguisher

1.) Aim at the base of the fire

A nurse who is teaching a group of adults ages 20 to 40 years old about safety is going to ensure that which topic is a priority? 1.) Automobile crashes 2.) Drowning and firearms 3.) Falls 4.) Suicide and homicide

1.) Automobile crashes When educating a group of young to middle-aged adults on safety, it is important to instruct them on the leading cause of injuries in this group.

What are the effects of massage as a manual healing method? Select all that apply 1.) Communication and caring 2.) Mental and physical relaxation 3.) Increased muscle strength 4.) Speeds the removal of waste products 5.) Lowers blood pressure and heart rate

1.) Communication and caring, 2.) Mental and physical relaxation, 4.) Speeds the removal of waste products, and 5.) Lowers blood pressure and heart rate Massage is a way of communicating without words, including the caring intent of the provider. It provides mental and physical relaxation. Massage speed the removal of metabolic waste products, allowing more oxygen and nutrients to reach the cells and tissues. It lowers blood pressure and slows the heart rate.

The nurse, at change of shift report, learns that one of the clients in his care has bilateral soft wrist restraints. The client is confused, is trying to get out of bed, and had pulled out the IV line, which was subsequently reinserted. Which action(s) by the nurse is appropriate? Select all that apply 1.) Document the behavior(s) that require continued use of the restraints 2.) Ensure that the restraints are tied to the side rails 3.) Provide range of motion exercises when the restraints are removed 4.) Orient the client 5.) Assess the tightness of the restraints

1.) Document the behavior(s) that require continued use of the restraints; 3.) Provide range of motion exercises when the restraints are removed; 4.) Orient the client; and 5.) Assess the tightness of the restraints Standards require documentation of the necessity for restraints. The implementation of range of motion exercises prevents joint stiffness and pain from disuse. Orienting the client helps the nurse determine the necessity of the restraint.

When caring for a single client during one shift, it is appropriate for the nurse to reuse only which of the following personal protective equipment? 1.) Goggles 2.) Gown 3.) Surgical Mask 4.) Clean Gloves

1.) Goggles Unless overly contaminated by material that has splashed in the nurse's face and cannot be effectively rinsed off, goggles may be worn repeatedly.

The nurse is caring for a client with a health care associated infection caused by methicillin-resistant Staphylococcus aureus. The nurse prepares to irrigate the wound and apply a new dressing. Which protective interventions should the nurse use to perform this procedure? Select all that apply 1.) Put on a mask 2.) Don gown and gloves 3.) Apply shoe protectors 4.) Wear a pair of protective goggles 5.) Have the client wear a mask and goggles

1.) Put on a mask; 2.) Don gown and gloves; 4.) Wear a pair of protective goggles

Before meeting with a client with a terminal illness, a new graduate nurse reviews information on spirituality. Which is the best explanation of spirituality? 1.) That which gives people purpose and meaning in their lives 2.) A formalized religious dogma 3.) A nondenominational community service 4.) People being responsible for their life patterns

1.) That which gives people purpose and meaning in their lives Spirituality gives us purpose and meaning in life; involves a relationship with oneself, others, and a higher power, and involves finding significant meaning in the entirety of life.

What is a rationale for assessment of clients' use of herbs? 1.) There are potential adverse interactions between some herbs and some medications 2.) Clients should not take anything that is not prescribed by the primary care provider 3.) These data will contribute to the body of knowledge on the use of herbs 4.) It is important to establish a pattern that clients tell nurses everything

1.) There are potential adverse interactions between some herbs and some medications Serious interactions can occur between herbs and medications.

Your friend is considering in vitro fertilization in hopes of becoming pregnant. Which one of the following is an accurate statement? 1.) There is some evidence that acupuncture improves the chance of pregnancy in this situation 2.) Massage therapy may increase your sense of relaxation, which may help in getting pregnant 3.) Ask your doctor about which herbs will increase the likelihood of pregnancy 4.) Research suggests that yoga improves the chance of pregnancy in this situation

1.) There is some evidence that acupuncture improves the chance of pregnancy in this situation

Which is the most effective nursing action for preventing and controlling the spread of infection? 1.) Through hand hygiene 2.) Wearing gloves and masks when providing direct client care 3.) Implementing appropriate isolation precautions 4.) Administering broad-spectrum prophylactic antibiotics

1.) Through hand hygiene Since the hands are frequently in contact with clients and equipment, they are the most obvious source of transmission.

The nurse is assisting with planning care for a client with an internal radiation implant. Which should be included in the plan of care? Select all that apply 1.) Wearing gloves when emptying the client's bedpan 2.) Keeping all linens in the room until implant is removed 3.) Wearing a film (dosimeter) badge when in the client's room 4.) Wearing a lead apron when providing direct care to the client 5.) Placing the client in a semiprivate room at the end of the hallway

1.) Wearing gloves when emptying the client's bedpan; 2.) Keeping all linens in the room until implant is removed; 3.) Wearing a film (dosimeter) badge when in the client's room; and 4.) Wearing a lead apron when providing direct care to the client

Which behavior is an initial step in culturally responsive nursing practice? 1.) Help the client recognize the need to adapt health practices to fit commonly accepted practices 2.) Discuss the meaning of the medical regimen with the client 3.) Inform the client that lack of adherence to the medical regimen may be detrimental 4.) Ask a cultural broker to explain the relevance of the intervention

2. Discuss the meaning of the medical regimen with the client Cultural differences may result in various interpretations of a medical regime. Cultural competence results in recognition of the right "not to fit."

A client with strong preferences for folk healing methods would prefer which of the following to treat sinus infections? 1.) Hospitalization 2.) Steam humidifier 3.) Antibiotic therapy 4.) "Watch and Wait"

2. Steam humidifier Steam is a natural substance and would be compatible with folk healing preferences.

A client asks how herbs are similar to prescribed medications. What is the nurse's best answer? 1.) "They are nothing alike. You should ask your doctor these types of questions." 2.) "Thirty percent of current prescription drugs are derived from plants." 3.) "Medications are much more effective than herbs." 4.) "Herbs are more dangerous than prescribed medications."

2.) "Thirty percent of current prescription drugs are derived from plants." Thirty percent of current prescription drugs are derived from plants.

The emergency department nurse receives a telephone call and is informed that a tornado has hit a local residential area and numerous causalities have occurred. The victims will be brought to the emergency department. Which should be the initial nursing action? 1.) Prepare the triage room 2.) Activate the agency emergency response plan 3.) Obtain additional supplies from the central supply department 4.) Obtain additional nursing staff to assist with treating casualties

2.) Activate the agency emergency response plan

The client is a chronic carrier of infection. To prevent the spread of the infection to other clients or health care providers, the nurse emphasizes interventions that do which of the following? 1.) Eliminate the reservoir 2.) Block the portal of exit from the reservoir 3.) Block the portal of entry into the host 4.) Decrease the susceptibility of the host

2.) Block the portal of exit from the reservoir Blocking the movement of the organism from the reservoir will succeed in preventing the infection of any other individuals.

Which nursing action is most likely to create a healing environment? 1.) Use technology to prevent health care associated infections 2.) Empower clients to make healthy decisions for themselves 3.) Assist clients to obtain a safe and comfortable place to live 4.) Ensure that primary care providers' orders are carried out

2.) Empower clients to make healthy decisions for themselves Healing environments are created when nurses empower clients to make healthy decisions

From the perspective of traditional Chinese medicine, which is the best definition of disease? 1.) Imbalance or disruption in food digestion 2.) Imbalance or interruption in the flow of qi 3.) Imbalance or disruption in key social relationships 4.) Imbalance or disruption in thoughts or emotions

2.) Imbalance or interruption in the flow of qi Qi is the flow of energy in the body that must be uninterrupted for a person to be in a healthy state. All other imbalances may result from an imbalance in the flow of qi or flow of vital energy through specific anatomic points along the surface of the body.

A client who speaks limited English requires instructions for a test. No one at your agency speaks the person's language. What is the nurse's best approach? 1.) Provide the instructions in writing 2.) Locate a professional interpreter 3.) Ask a family member to translate on the phone 4.) Document that the required instruction is not possible

2.) Locate a professional interpreter If an interpreter is not available at your agency, you must still meet the expectations of providing information in a way the client can comprehend it.

A client is being admitted to the hospital because of a seizure that occurred at his home. The client has no previous history of seizures. In planning the client's nursing care, which of the following measures is most essential at this time of admission? Select all that apply 1.) Place a padded tongue depressor at the head of the bed 2.) Pad the bed with blankets 3.) Inform the client about the importance of wearing a medical identification tag 4.) Teach the client about epilepsy 5.) Test oral suction equipment

2.) Pad the bed with blankets and 5.) Test oral suction equipment These are measures needed to keep the client safe in the event of another seizure.

After teaching a client and family strategies to prevent infection prevention, which statement by the client would indicate effective learning has occurred? 1.) "We will use antimicrobial soap and hot water to wash our hands at least three times per day." 2.) "We must wash or peal all raw fruits and vegetables before eating them." 3.) " A wound or sore is not infected unless we see it draining pus." 4.) " We should not share toothbrushes but it is OK to share towels and washcloths."

2.) Raw foods touched by human hands can carry significant infectious organisms and must be washed or peeled.

The nurse evaluates the chart of a 65 year old client with no apparent risk factors and concludes that which immunizations are current? Select all that apply 1.) Last tetanus booster was at age 50 2.) Receives a flu shot every year 3.) Has not received the hepatitis B vaccine 4,) Has not received the hepatitis A vaccine 5.) Has not received the herpes zoster vaccine

2.) Receives a flu shot every year; 3.) Has not received the hepatitis B vaccine; 4.) Has not received the hepatitis A vaccine Flu shots are recommended for all adults over age 50. Only adults at risk need to receive hepatitis A and B vaccine.

The nurse obtains a prescription to restrain a client using a belt (safety) restraint and instructs the CNA to apply the restraint. Which observation, if made by the nurse, indicates unsafe application of the restraint? 1.) A safety knot is made in the restraint strap 2.) The restraint straps are safely secured to the side rails 3.) The restraint strap does not tighten when force is applied against it 4.) The restraint is secure, and the client is able to turn from back to side

2.) The restraint straps are safely secured to the side rails The restraint strap is secured to the bed frame never to the side rail, to avoid accidental injury in case the side rail is released.

In initiating care for a client from a different culture than the nurse, which of the following would be an appropriate statement? 1.) "Since, in your culture, people don't drink ice water, I will bring you hot tea." 2.) "Do you have any books I could read about people of your culture." 3.) "Please let me know if I do anything that is not acceptable in your culture." 4.) "You will need to set aside your usual customs and practices while you are in the hospital."

3. "Please let me know if I do anything that is not acceptable in your culture." The nurse should indicate that he or she is open to diverse views and practices

An outcome of achieving national cultural health goals would be which of the following? 1. All cultures receive the same health care. 2. All people have the same life expectancy. 3. All U.S. residents have access to the same quality of health care. 4. All cultures are fully assimilated into the dominant society.

3. All U.S. residents have access to the same quality of health care. National cultural health goals include providing equal access to quality health care for everyone.

The major factor contributing to the increased emphasis on the need for proficiency in cultural nursing practice in the United States is which of the following? 1.) An increasing birth rate 2.) Increased access to health care services 3.) Demographic changes 4.) A decreasing rate of immigration

3. Demographic changes There is an ongoing shift in the U.S. population that includes a decreasing number of White Americans and an increasing number of other cultural groups

Which behavior is most representative of a culturally competent nurse? 1.) Helps clients of Native American heritage identify ways to relate more to their culture 2.) Helps parents of Latino heritage recognize that their children need to speak English 3.) Interprets and validates beliefs of a client with African American heritage 4.) Asks a nurse of Japanese heritage to teach others dosage calculations since Asians are good at math

3. Interprets and validates beliefs of a client with African American heritage Culturally competent implies that, within the delivered care, the nurse understands and attends to the total context of the client's situation, including awareness of immigration, stress factors, and cultural differences.

The nurse enters a client's room and finds that the wastebasket is on fire. The nurse quickly assists the client out of the room. Which is the next nursing action? 1.) Call for help 2.) Extinguish the fire 3.) Activate the fire alarm 4.) Confine the fire by closing the room door

3.) Activate the fire alarm

A client askes the nurse the differences between traditional therapies and alternative therapies. What is the best response? 1.) Alternative therapies cost less than traditional therapies 2.) Alternative therapies are used if traditional therapies are ineffective 3.) Alternative therapies can be as effective as traditional therapies for some conditions 4.)Alternative therapies utilize products form nature but traditional therapies do not

3.) Alternative therapies can be as effective as traditional therapies for some conditions Although the effectiveness of alternative therapies is sometimes not scientifically established, many people report significant benefit form them for a wide variety of conditions

A mother calls a neighborhood nurse and tells the nurse that her 3 year old child has just ingested liquid furniture polish. Which action should the nurse instruct the mother to take first? 1.) Induce vomiting 2.) Call an ambulance 3.) Call the poison control center 4.) Bring the child to the emergency department

3.) Call the poison control center If a suspected poisoning occurs, the poison control center should be contacted immediately.

Medication errors can place the client at significant risk. Which practice(s) will help decrease the possibility of errors? Select all that apply 1.) Hire only competent nurses 2.) Improve the nurse's ability to multitask 3.) Establish a reporting system for "near misses" 4.) Communicate effectively 5.) Create a culture of trust

3.) Establish a reporting system for "near misses"; 4.) Communicate effectively; and 5.) Create a culture of trust Reviewing near misses could identify flaws in the system or practices that placed the client at risk. Communication among staff and with clients will increase the efficiency and create an atmosphere where nurses are willing to discuss errors openly so that the flaws in the system can be corrected.

In caring for a client on contact precautions for a draining infected foot ulcer, which action should the nurse perform? 1.) Wear a mask during dressing changes 2.) Provide disposable meal trays and silverware 3.) Follow standard precautions in all interactions with the client 4.) Use surgical aseptic technique for all direct contact with the client

3.) Follow standard precautions in all interactions with the client Standard precautions include all aspects of contact precautions with the exception of placing the client in a private room.

When planning to teach health care topics to a group of male adolescents, which topic should the nurse consider a priority? 1.) Sports contribute to an adolescent's self esteem 2.) Sunbathing and tanning beds can be dangerous 3.) Guns are the most frequently used weapon for adolescent suicide. 4.) A driver's education course is mandatory for safety

3.) Guns are the most frequently used weapon for adolescent suicide Suicide and homicide are two leading causes of death among teenagers. Adolescent males commit suicide at a higher rate than adolescent females.

The nurse applies wrist restraints, prescribed to prevent a client from pulling out a nasogastric tube. How should the nurse determine that the restraints are not too constrictive? 1.) Observe the skin in the wrist area for redness 2.) Check the temperature of the skin in the hands 3.) Place two fingers under the restraint to determine snugness 4.) Remove the restraint and exercise the extremity in 2 hours

3.) Place two fingers under the restraint to determine snugness Limb restraints are often prescribed to prevent clients from pullout out tubes and injuring themselves. The restraint is prescribed for 24 hours, and the nurse must verify that the restraint is protecting the client from self injury but not too constrictive to impair circulation or harm the skin. Limb restraints are made with padding to protect the client's skin.

A nurse sees smoke emerging from the suction equipment being used. Which is the greatest priority in the event of a fire? 1.) Report the fire 2.) Extinguish the fire 3.) Protect the clients 4.) Contain the fire

3.) Protect the clients In the event of a fire, the nurse's priority responsibility is to rescue or protect the clients under his or her care.

An 87 year old man is admitted to the hospital for cellulitis of the left arm. He ambulates with a walker and takes a diuretic medication to control symptoms of fluid retention. Which intervention is most important to protect him from injury? 1.) Leave the bathroom light on 2.) Withhold the client's diuretic medication 3.) Provide a bedside commode 4.) Keep the side rails up

3.) Provide a bedside commode The placement of the bedside commode next to his bed will assist in decreasing the number of steps he is required to ambulate. This will assist in protecting him from injury due to falls

A mother and her 3 year old live in a home built in 1932. Which NANDA nursing diagnosis is most applicable for this child? 1.) Risk for Suffocation 2.) Risk for Injury 3.) Risk for Poisoning 4.) Risk for Disuse Syndrome

3.) Risk for Poisoning A home that was built prior to 1978 has lead based paint. The ingestion of lead based paint chips places that child at risk for elevated serum lead levels and neurologic deficits.

The nurse determines that a field remains sterile if which of the following conditions exist? 1.) Tips of wet forceps are held upward when held in ungloved hands 2.) The field was set up 1 hour before procedure 3.) Sterile items are 2 inches from the edge of the field 4.) The nurse reaches over the field rather than around the edges

3.) Sterile items are 2 inches from the edge of the field All items within 1 inch of the edge of the sterile field are considered contaminated because the edge of the field is in contact with unsterile areas.

The nurse should institute which interventions for a client diagnosed with Clostridium difficile? Select all that apply 1.) Wear a mask if within 3 feet of the client 2.) Place a mask on the client when client is outside the room 3.) Wear gloves and gown while in the room caring for the client 4.) Use soap and water, not alcohol-based hand rub, for hand hygiene 5.) Keep the door of the room shut except when entering or exiting the client's room

3.) Wear gloves and gown while in the room caring for the client and 4.) Use soap and water, not alcohol-based hand rub, for hand hygiene

What is the most productive method of gathering assessment data regarding heritage? 1.) Physical exam 2.) Medical history 3.) Blood analysis 4.) Traditional beliefs and practices checklist

4. Traditional beliefs and practices checklist To gather assessment data regarding the client's heritage, nurses must explore client's beliefs and practices. A good beginning would be to ask clients to indicate from the checklist which apply to them.

A licensed practical nurse (LPN) attends a session about bioterrorism agents including anthrax. Which statement by an attendee demonstrates the need for further teaching about anthrax? 1.) Anthrax is treated with antibiotic medications 2.) The most lethal form of anthrax is contacted by inhalation of the spores 3.) Anthrax can be transmitted by consumption of meat from an infected animal 4.) Anthrax bacteria produces a neurotoxin leading to a serious, possibly fatal paralysis

4.) Anthrax bacteria produces a neurotoxin leading to a serious, possibly fatal paralysis

A client asks the nurse to state one of the primary principles associated with naturopathy. Which of the following is the best response? 1.) A higher being guides the learning needed to treat disease 2.) It focuses on environmental causes when treating illnesses 3.) It focuses on early detection and treatment of disease 4.) It is a way of life to maintain health and prevent disease

4.) It is a way of life to maintain health and prevent disease Naturopathy focuses on the total person. The primary focus is disease prevention.

Which oils may be placed directly on the skin? 1. Rose and Orange 2. Green apple and jasmine 3. Clary sage and rosemary 4. Lavender and tea tree

4.) Lavender and tea tree The oils in 1, 2, and 3 will burn the skin if they are not diluted in a carrier oil.

When applying sterile gloves (open method), the cuff of the first glove rolls under itself about 0.5 cm. What is the best action for the nurse to take? 1.) Remove the glove and start over with a new pair 2.) Wait until the second glove is in place and then unroll the cuff with the other sterile hand 3.) Ask a colleague to assist by unrolling the cuff 4.) Leave the cuff rolled under

4.) Leave the cuff rolled under It should not be necessary to unroll this small edge of the cuff. The most important consideration is the sterility of the fingers and hand that will be used to perform the sterile procedure.

Which nursing intervention is the highest in priority for a client at risk for falls in a hospital setting? 1.) Keep all of the side rails up 2.) Review prescribed medications 3.) Complete the "get up and go" test 4.) Place the bed in the lowest position

4.) Place the bed in the lowest position Placing the bed in the lowest position results in a client falling the shortest distance. The client is least likely to fall when getting out of a bed that is at an appropriate height.

A 75 year old client, hospitalized with a cerebrovascular accident (stroke), becomes disoriented at times and tries to get out of bed, but is unable to ambulate without help. What is the most appropriate safety measure? 1.) Restrain the client in bed 2.) Ask a family member to stay with the client 3.) Check the client every 15 minutes 4.) Use a bed exit safety monitoring device

4.) Use a bed exit safety monitoring device This is an intervention that can allow the client to feel independent and also alert the nursing and nursing staff when the client needs assistance. It is the most realistic answer that promotes client safety.

Reflexology

A form of acupuncture

Prejudice

A preconceived notion or judgement that is not based on sufficient knowledge

Ethnicity

A relationship among individuals who believe that they have distinctive characteristics that make them a group

Guided imagery

A state of focused attention that encourages changes in attitude, behavior, and physiological reactions

For a school-age child who enjoys riding a bicycle, which is the priority nursing diagnosis? a. Risk for injury b. Risk for falls c. Risk for impaired skin integrity d. Risk for impaired mobility

ANS: A Until additional information is gathered, the nurses' first concern for a school-age child who rides a bike is risk for injury, as the parents and child may have insufficient knowledge of safety precautions. Nurses need to ensure that the patient and the family receive adequate education about the need for wearing helmets and other protective equipment during bicycling. While the child is also at risk for falling from the bike, this is not your primary concern. Risk for impaired skin integrity and impaired mobility would only be concerns if the child were to experience a bicycling-related injury.

Which behavior by the nurse during medication administration is most likely to cause a medication error in a 40-year-old patient on a medical/surgical unit? (Select all that apply.) a. Verifies the patient's identity calling the patient by name b. Calls the pharmacist to check on the medication dosage c. Takes a telephone call from the doctor about the patient while preparing the medication d. Fails to weigh the patient prior to giving the medication e. Double-checks the right route before administering medication

ANS: A, C Two forms of identification should always be used to check the patient's identity prior to administering medications. Thus, calling the patient by name is an inadequate means of properly identifying a patient prior to med administration. Taking a phone call is an interruption in the process of medication administration that can result in an error. Double-checking the route and calling the pharmacist to ensure the dosage is proper for this patient are means by which medication errors can be reduced. Finally, for most adult patients weight-based dosing is not performed.

Select the most appropriate side rail regime for an elderly patient who intermittently calls for assistance: a. one top side rail raised on the patient's dominant side b. two top side rails raised to promote bed mobility c. three side rails up with bottom rail closest to bathroom down d. four side rails up to prevent the patient getting up without assistance

ANS: C Keeping three side rails up with the rail closest to the bathroom down is the best option for this patient. One side rail will be inadequate to promote some patient independence with bed mobility. While two side rails are supportive of some independent bed mobility, elevating a third rail can serve as an additional support for bed mobility and a reminder not to get up alone. Raising all four side rails is considered a form of physical restraint, requiring an order from a primary care provider. Patients are at risk for strangulation, entrapment, and entanglement injuries and death when all four side rails are up. A bed alarm should also be applied to alert the staff when the patient is attempting to get up alone.

Which patient appears to be at greatest risk for falls? a. 66-year-old woman post-op, A&O x 3, continuous IV, and narcotic pain meds b. 71-year-old man with pneumonia, A&O x 2, on O2, and continuous IV c. 76-year-old man with acute confusion, A&O x 1, incontinent, and continuous IV d. 80-year-old woman post-op, A&O x 3, narcotic pain meds, and continuous IV

ANS: C The 76-year-old man with acute confusion and incontinence with a continuous IV appears to be at greatest risk for falls. While the other patients also have sources of tethering (e.g., oxygen and IV tubing) and narcotic pain meds, the acute confusion and incontinence along with the IV tethering produce the most significant risk.

When a fire occurs in a health care agency, in which sequence should actions be performed? a. Pull the alarm. Assist patients. Secure area by closing doors. Spray extinguisher. b. Remove oxygen source. Aerate the fire. Call the operator. Evacuate patients. c. Rescue the patients. Alarm sounded. Contain the fire. Extinguish fire. d. Remove fire source. Alarm sounded. Close the doors. Evacuate patients.

ANS: C Remember what the letters of the RACE acronym stand for and that your first priority is the safety of the patients. First, "R" involves rescuing patients in close proximity to the fire. Second, "A" indicates that the fire alarm must be sounded and the exact location of the fire reported. Third, "C" involves containing the smoke and the fire, which include the closing of doors and turning off oxygen. Finally, the "E" indicates after all patients are rescued and if the fire is small enough, an attempt may be made to extinguish it.

Identify all nursing interventions that would be required when caring for a restrained patient: a. Remove restraints q1h and inspect the skin. b. Check on the patient every 30 minutes and ensure needs are met. c. Renew restraint orders every shift. d. Remove restraints as soon as patient's condition allows.

ANS: D Restraints are used today only when necessary for the protection of the patient and/or the nurse. Thus, nurses should remove restraints ASAP when the patient is no longer a danger to him/herself or others. The frequency with which restraints need to be released and assessments for complications performed is every two hours. The patient also needs to be checked every hour to ensure that basic needs are met (e.g., food, fluids, toileting). Restraint orders must be renewed every 24 hours.

What other health care professional should the nurse consult when a patient has difficulty with activities of daily living and why? a. Occupational therapist to evaluate the ability to perform ADLs b. Physical therapist to evaluate the patient's need for assistive devices c. Social worker to arrange for needed assistive devices d. Area agency on aging to arrange for Meals on Wheels

Answer: a An evaluation by an OT is the first step in identifying the details of the ADL safety concerns. Other evaluations and services may be warranted and arranged after the OT evaluation reveals some basic needs.

A 56-year-old man who has been staying at a cabin while hunting arrives at the emergency department with complaints of dizziness, light-headedness, and nausea. What does the nurse initially suspect? a. Carbon monoxide poisoning b. Lead poisoning c. Radon exposure d. Food poisoning

Answer: a Symptoms of carbon monoxide poisoning are nausea, dizziness, and light-headedness. Carbon monoxide poisoning can result from using camp stoves inside and burning objects in poorly vented fireplaces. Lead poisoning resulting in neurologic symptoms is more common in children exposed to lead-based paints. Symptoms of radon exposure include persistent cough, hoarseness, and breathing difficulties. Symptoms of food poisoning usually include nausea, vomiting, and diarrhea.

Which measure can the nurse teach to prevent poisoning of children? (Select all that apply) a. Instill safety latches on reachable cabinets b. keep syrup of ipecac on hand c. Use childproof caps on medications d. use a plunger rather than a chemical drain cleaner e. keep cleaning supplies under the kitchen sink

Answer: a, c, d Child locks for cabinets and childproof caps on medication bottles are recommended to prevent poisoning. The use of alternatives (e.g., plungers) rather than toxic chemicals (e.g., Drano) is recommended to prevent ingestion of deadly substances. Syrup of ipecac has been used in the past to treat poisoning after it occurred and is not considered a preventive measure. Keeping cleaning supplies under the kitchen sink is dangerous because the area is within reach of children.

An elderly client residing in the community with cardiopulmonary compromise and impaired ability to perform activities of daily living presents safety concerns to the nurse. Which is the greatest concern? a. Ability to obtain and take medications correctly b. Ability to safely get on and off a toilet c. Ability to safely procure food and prepare meals d. Ability to safely eat without choking

Answer: b A patient with cardiopulmonary compromise may exhibit symptoms such as shortness of breath, leading to subsequent activity intolerance and difficulty performing ADLs. An individual may be unable to safely get off and on a toilet, leading to an increased risk of falling, which is the primary concern of the nurse. Although the other concerns may apply, they are less likely to be related to cardiopulmonary compromise.

Which restraint-free alternative is best for the nurse to use for an 84-year-old patient after hip replacement who has acute confusion and incontinence? a. A room near the nurses' station and decreased sensory stimuli b. A pressure sensor alarm and a room near the nurses' station c. Side rails up and decreased sensory stimuli d. A 24-hour sitter and the patient's favorite TV program

Answer: b Patients with acute confusion may not remember to call for assistance before getting up, especially if they have had an episode of incontinence. A pressure sensor alarm that can be used in a bed or chair should be implemented as a priority intervention along with moving the patient to a room near the nurses' station, where the patient can be more closely monitored. Although decreasing sensory stimuli may help a patient with acute confusion, it is not a priority intervention. A 24-hour sitter is costly and used only after all other restraint-free alternatives are exhausted.

The nurse is performing a fall risk assessment on a newly admitted patient. Which finding is a known risk factor for falls? a. Medications b. Urinary incontinence c. Multiple comorbidities d. Malnutrition

Answer: b Urinary incontinence, a known factor that increases fall risk, is included on the Johns Hopkins Hospital Fall Assessment Tool and Hendrich II Fall Risk Model. Although the effects of specific medications (e.g., antiepileptics, narcotics) may increase the risk of falls, medication use alone does not. Comorbidities may increase fall risk, but the total number of comorbidities does not have an independent effect. Malnutrition alone does not increase fall risk, but conditions resulting from it, such as muscle wasting and deconditioning leading to weakness, can increase fall risk.

When teaching a patient about fire safety, which activity does the nurse know is the leading cause of fire-related death? a. cooking b. playing with matches c. smoking d. heating with kerosene heaters

Answer: c Smoking is the leading cause of fire-related deaths, 80% of which occur in the home. Cooking, kerosene heaters, and children playing with lighters and matches are common causes of house fires.

Which activity would be most appropriate for the RN to delegate to unlicensed assistive personnel? a. Assessing the patient for fall risk and complications of restraint use b. Evaluating the patient's ability to perform ADLs c. Assisting with or performing the patient's ADLs d. Teaching the patient use of assistive devices

Answer: c UAP, such as patient care technicians and nursing assistants, provide hands-on care for patients who may require complete care or total assistance with their ADLs. However, RNs are responsible for supervising and guiding the UAP so that direct care is provided in a safe manner. RNs are responsible for performing patient assessments, and the OT evaluates the patient's ability to perform ADLs. A physical therapist evaluates mobility and initially teaches the patient to use an assistive device. If use of assistive devices needs reinforcement, the RN does the teaching.

A patient is ordered to have a urine culture to rule out MRSA. When obtaining this specimen, which PPE should the nurse don? a. Gloves, mask, eye shield b. Gloves, gown, shoe covers c. Gloves, mask, hat d. Gloves, gown, eye shield

Answer: d Because areas that can serve as ports of entry for MRSA must be covered, the required PPE includes gloves, a gown, and an eyeshield. Gloves and a gown are worn to prevent urine from coming into contact with open areas on the skin. An eyeshield protects the eyes from a urine splash. A mask is not required in this case because MRSA is not suspected in the respiratory tract. A hat and shoe covers are not needed because these skin surfaces typically are covered with hair and shoes, respectively

When working with radiation diagnostics or treatments, which preventive measure should be followed to avoid exposure? (Select all that apply) a. Using lead shielding of patients and staff b. keeping staff at the farthest distance possible from the radiation source c. Limiting the length of exposure d. wearing a badge to monitor the length of exposure e. following procedures and safety checks

Answers: a, b, c, d, e All of these preventive measures can be taken to avoid radiation exposure. Lead shielding should be used for patients and staff. Staff should be kept at the farthest distance possible from the radiation source, and the length of exposure should be limited. To track exposure and ensure safety, health care professionals working with radiation or radioactive materials should wear a device or badge that is periodically turned into monitor cumulative radiation exposure levels. All equipment should be maintained and properly used according to manufacturers' guidelines.

Discrimination

Differential and negative treatment of individuals on the basis of their race, ethnicity, gender, or other group membership

Use the nursing process to assess adults for safety issues.

Health history and physical assessment should dictate specific safety questions about: -Safety in the home -Poisoning -Fire and electrical hazards -Biohazards -Home temperature safety -Tripping and falling hazards -Outside environment -Work Use the John Hopkins Hospital Fall Assessment Tool -seven item tool, used nationally and internationally in hospitals, can be completed quickly and easily, includes fall prevention intervention guidelines Morse Fall Scale -six item fall risk assessment tool, widely used nationally and internationally since the late 1980s in acute care and long term care settings Hendrich II Fall Risk Model --eight factor assessment model, well established and used widely in acute care settings to assess the fall risk of patients

Acculturation

Incorporation of traits from another culture

What is a commonly used tool to better understand the client's perspective?

LEARN Listen actively with empathy to the client's perception of the problem Explain what you think you heard/ask for clarification Acknowledge the importance of what is said and what it means Negotiate the plan of care by collaborating with the client and others

Ethnocentrism

One's own ethnic beliefs, customs and attitudes are correct and thus superior ones

Biofeedback

Person learns to control certain physiological responses of the body

Complementary medicine

Practices that do not follow conventional biomedical explanations (often handed down through the generations)

Assimilation

Process by which a person develops a new cultural identity

A client with poor nutrition enters the hospital for treatment of a puncture wound. An appropriate nursing diagnosis would be?

Risk for Infection because a malnourished client with a wound is less able to resist an infection

Diversity

State of being different

Biomedicine

Term to describe Western medicine practices

Culture shock

The feeling of disorientation experienced by someone who is suddenly subjected to an unfamiliar culture, way of life, or set of attitudes

Use the nursing process to identify nursing diagnosis related to safety issues

The most common nursing diagnoses directly associated with safety concerns include: -Risk for injury -Risk for falls -Risk for poisoning -Risk for infection -Risk for aspiration

What are the national patient safety goals?

They improve patient safety with a focus on current problems and how to solve them. Goals: -identify patients correctly -improve staff communication -use meds safely -use alarms safely -prevent infection -identify patient safety risks (suicide, falls, home oxygen use, and preventing pressure ulcers) -prevent mistakes in surgery

Culture

Thoughts, communications, actions, customs, beliefs, values and institutions of racial, ethnic, religious or social groups

Herbal medicine

Treating illnesses with herbs

Ayurveda

Viewed as a state of imbalance among the body's systems

How do you know something is infected?

When inflammation sets in. Inflammation is an adaptive mechanism that destroys or dilutes the injurious agent, prevents further spread of the injury, and promotes the repair of damaged tissue.

the nurse has investigated safety hazards and recognizes that the leading cause of unintentional poisoning results from: a. carbon monoxide b. contaminated food c. decorative plants d. lead

a. carbon monoxide

a 79 year old resident in a long term care facility is known to "wander at night" and has fallen in the past. which of the following is the most appropriate nursing intervention? a. the patient should be checked frequently during the night b. an abdominal restraint should be placed on the patient during sleeping hours c. a radio should be left playing at the bedside to assist in reality orientation d. the patient should be placed in a room away from the activity of the nursing station

a. the patient should be checked frequently during the night

What are the pt. bill of rights?

all patients and clients receiving services from state-operated facilities have certain rights under state law

What is a systemic infection?

an infection throughout the body

two of the commonly discussed forms of bioterrorism are :

anthrax & smallpox

Why are children at risk for injury?

because they are still learning what is harmful

Why are infants/newborns at risk for injury?

because they cannot fend for themselves

negative outcomes from the use of physical restraints

compromised circulation, impaired skin and tissue integrity, incontinence, mental status changes, difficulty breathing, pneumonia, impaired hydration and nutrition, aspiration, strangulation, entrapment, muscle atrophy, reduced bone mass, contracture, fractures, death

An ambulatory patient is admitted to the extended care facility with a diagnosis of Alzheimer disease. in using a fall assessment tool, the nurse knows that the greatest indicator of risk is: a. confusion b. impaired judgement c. sensory deficits d. history of falls

d. history of falls

suffocation can occur as a result of

drowning, choking, and smothering

What are nosocomial infections?

hospital acquired infections

What is a local infection?

it is limited to a specific part of the body where the microorganism remains

What is medical asepsis?

measures used to reduce and prevent the spread of pathogens

how can a nurse avoid medication error

medication errors can be avoided by carefully checking in accordance with the six rights, communicating with colleagues, and verifying orders with the providers. special care must be taken with sound alike or similarly spelled medications. in addition identifying the patient is crucial

identify how the following can affect individual safety. a. musculoskeletal b. neurologic function

musculoskeletal: restrictions in range of motion and diminished strength can lead this subsequent loss of balance and unsteady gait. these changes can affect overall mobility, including the ability to transfer, stand, and walk. with limitations in mobility, the propensity for falling is increased. neurologic: changes in mental status can occur, judgement may become altered, and safety awareness may become compromised. with an alteration in any of the five senses, a variety of safety risks may result, such as an inability to smell smoke or hear an alarm

which teaching should be included for an information session to new parents on infant safety?

placing infants on their backs for sleep, never leaving the baby unattended, correctly using rear facing car seats and carriers, obtaining approved cribs and toys, child proofing the home, keeping small objects and dangerous substances out of reach, fencing swimming pools, and never leaving children in a car alone

What are unintentional injuries?

results from incidents such as falls, motor vehicle crashes, poisonings, drownings, fire associated injuries, suffocation by ingested objects, and firearms

identify at least two possible safety related nursing diagnoses and goals/outcomes

risk for injury, risk for falls, risk for poisoning, risk for infection patient will experience no injuries while hospitalized

assessment of a patient with a restraint in place should include

skin integrity, sensation, circulation patients with vest restraints need to have respiratory status evaluated mental and emotional status should be evaluated also

adolescents are susceptible to which kind of safety hazards?

substance abuse, psychological issues, securely related activities, motor vehicle accidents, and overexposure to TV and internet

What is cultural competence?

the attitudes, knowledge, and skills necessary for providing quality care to diverse populations.

What is active immunity?

the immunity that results from the production of antibodies by the immune system in response to the presence of an antigen.

What is surgical asepsis?

the process of creating and maintaining an area that is completely free of pathogens (sterile technique)

Why are the elderly at risk for injury?

they have difficulty with movement and diminished sensory neuroligc acuity

What is passive immunity?

this is where the host receives natural (from a nursing mother) or artificial (from an injection of immune serum) antibodies produced from another source

what are the sources of exposure of radiation exposure for nurses?

treatments, diagnostic tests

What sensory-perceptual alterations place people at risk for injury?

--impaired touch perception, hearing, taste, smell, and vision

When are restraints used?

-After all other measures fail to protect a person -To ensure the client's immediate physical safety, even if the client is not violent or self-destructive -seclusion may only be used for the management of violent or self-destructive behavior that is an immediate threat to the client's safety -may only be used when less restrictive interventions have been determined to be ineffective to protect the client, a staff member, or others from harm -the type or technique of restraint or seclusion used must be the least restrictive intervention that will be effective to protect the client, a staff member, or others from harm -must be implemented in accordance with safe and appropriate restraint and seclusion techniques per hospital policy -must be discontinued at the earlies possible time

What factors do we need to assess to determine if a client is at risk for infection?

-Age: w/advancing age the immune response become weaker -Heredity: some people have a genetic susceptibility to certain infections -Level of stress: stressors elevate blood cortisol levels; prolonged elevation decreases anti-inflammatory responses, depletes energy stores, leads to state of exhaustion, and decreases resistance to infection -Nutritional status: antibodies are proteins, the ability to synthesize antibodies may be impaired by inadequate nutrition -Current medical therapies: like radiation treatments for cancer not only destroy cancerous cells but also some normal cells -Certain medications: anticancer meds depress bone marrow function resulting in inadequate production of white blood cells; corticosteroids inhibit the inflammatory response -Any disease that lessens the body's defenses against infection: like chronic pulmonary disease, peripheral vascular disease, burns, leukemia, and aplastic anemia along with diabetes mellitus