Chapter 27 Assessment Related to Safety

A patient is on a large number of medications and the nurse is concerned about the patient's ability to manage all the medications at home. Which of the following questions should the nurse ask to assess the patient's potential safety risk? (Select all that apply) A. Do you take your medications consistently? B. Do any young children live in the home? C. Do you know how to take your medications? D. Do you know when to take your medications? E. Do you know why you take all these medications?

A, C, D and E One question to assess the patient's potential medication safety risk is "Do you take your medications consistently?" One question to assess the patient's potential medication safety risk is "Do you know how to take your medications?" One question to assess the patient's potential medication safety risk is "Do you know when to take your medications?" One question to assess the patient's potential medication safety risk is "Do you know why you take all these medications?"

To assist with determining the patient's risk for injury and issues requiring further evaluation, the patient assessment should include which items? (Select all that apply) A. Subjective data related to the patient's symptoms B. Patient's family history C. Focused assessment of the affected body systems. D. Patient's history of exposures to environmental hazards. E. Subjective data related to the patient's chief complaint

A, C, D and E Subjective data related to the patient's symptoms are used to determine the patient's risk for injury and issues requiring further evaluation. Focused assessment of the affected body systems is used to determine the patient's risk for injury and issues requiring further evaluation. The patient's history of exposure to environmental hazards is used to determine the patient's risk for injury and issues requiring further evaluation. Subjective data related to the patient's chief complaint are used to determine the patient's risk for injury and issues requiring further evaluation.

The nurse is asking the patient a series of questions about the patient's activities of daily living. The patient asks the nurse why that information is important. What is the nurse's best response? A. "The answers to these questions will help us determine if you need any assistance at home." B. "This information will help your provider determine if you need to be placed in a skilled nursing facility." C. "The questions are designed to get you to think about going home from the hospital." D. "We use this information to determine if you live in an unsafe environment."

A. "The answers to these questions will help us determine if you need any assistance at home." The purpose of the questions is to assess the patient's need for assistance at home and ensure the patient's safety.

Educating patients about electrical cord safety is important in preventing what home safety hazards? A. Fires and falls B. Falls and outdoor safety hazards C. Chemical and carbon monoxide poisonings D. Fires and medication safety hazards

A. Fires and falls Educating patients about electrical cord safety is important in preventing fires and fall hazards, as frayed electrical cords can start fires and electrical cords in walking areas are trip hazards.

The nurse is caring for a confused 69-year-old male patient, who recently had a seizure at home and hit his head, sustaining a subdural hemorrhage. He has an IV infusion and is receiving Dilantin to prevent further seizures. The patient is to unable stand without assistance. According to the Hendrich II Fall Risk Model, what is the patient's fall risk? A. High risk B. Moderate risk C. Low risk D. Tool not appropriate

A. High risk The patient is a high risk for falls: Confusion - 4; Depression - 0; Altered elimination - 0; Dizziness - 0; Gender - 1; Any antiepileptic agents (Dilantin) - 2; Any benzodiazepine medications - 0; Get Up & Go Test - 4 = 11.

The nurse is caring for a 72-year-old female patient who is on bed rest following hip surgery for an injury sustained from a fall at home. The patient has a history of diabetes and ongoing dementia. She has an IV infusion, a nasogastric tube, and a urinary drainage catheter. According to the Morse Fall Scale, what is the patient's fall risk? A. High risk B. Moderate risk C. Low risk D. Tool not appropriate

A. High risk The patient is a high risk for falls: History of Falls - 25; Secondary diagnosis - 15; Ambulatory aid - 0; IV/Heparin lock - 20; Gait/transferring - 0; Mental status - 15 = 75 points.

An older adult patient is admitted with heat exhaustion. The nurse is concerned that the patient's home environment contributed to the problem. What question should the nurse ask the patient to obtain information about this issue? A. How do you cool your home? B. Do you use space heaters? C. Do you check for frays on electrical cords? D. Do you use an oven?

A. How do you cool your home? The nurse should ask how the patient keeps his or her home cool, as heat exhaustion is evidence of an overly warm environment.

The nurse is caring for a comatose patient with two intravenous (IV) access catheters and a urinary drainage catheter. What would be the patient's fall risk category using the Johns Hopkins Fall Assessment Tool? A. Low B. Moderate C. High D. Tool not appropriate

A. Low A patient who is comatose would be considered completely immobilized and would be considered a low fall risk based on the Category 1 criteria of the Johns Hopkins Fall Assessment Tool.

When should a nurse evaluate a patient's risk for falls? (Select all that apply) A. After a patient falls B. On admission C. Every day D. Per provider orders E. With any change in the patient's condition

B, C and E The nurse should evaluate a patient's risk for falls on admission. The nurse should evaluate a patient's risk for falls every day. The nurse should evaluate a patient's risk for falls with any change in the patient's condition.

The nurse is educating a patient about fire safety in the home. Which response would indicate that the patient needs further education? A. "All the electrical outlets have covers on them." B. "I like to shave with my electric razor when I am in the tub." C. "There is a fire extinguisher in the kitchen." D. "I have smoke detectors in each room."

B. "I like to shave with my electric razor when I am in the tub." Using an electric razor while in the bath tub is an electrical safety hazard and the patient should be counseled not to use electrical appliances around water.

A paraplegic patient is being prepared for discharge from a spinal cord rehabilitation unit. Which question is most important for the nurse to ask when performing a home safety assessment? A. Do you have a carbon monoxide detector? B. Do you have a plan to exit the home in case of an emergency? C. Where are your medications stored? D. Do you have a fire extinguisher?

B. Do you have a plan to exit the home in case of an emergency? Asking about a home exit plan in case of emergency is important for all patients, but it is extremely important for patients with limited mobility, as they may not be able to exit the home quickly in the event of a fire or other emergency.

To assess the patient's risk of health issues related to home safety, what question should the nurse ask? A. Do you have any safety concerns? B. Have you ever had a seizure? C. Are you stressed out or tired? D. Do you require assistance bathing?

B. Have you ever had a seizure? Asking if the patient has ever had a seizure helps the nurse identify a health issue that can pose a risk to the patient's safety, as patients may fall or injure themselves during seizures.

An older adult patient lives at home with an adult child and several young grandchildren. The nurse is educating the patient about hazards in the home. What information should the nurse include in the patient's education plan? A. Marinate meat in an airtight container on the kitchen counter to avoid food poisoning. B. Keep all household cleaners in a secure cabinet, as they can be poisonous. C. Have the gas company come to the house every six months to check for carbon monoxide, which can be lethal. D. Store all medications within easy reach so as to avoid over stretching and falling.

B. Keep all household cleaners in a secure cabinet, as they can be poisonous. The education plan should include information about keeping all household cleaners stored in a secure cabinet away from children and pets, as these are poisonous substances.

The nurse is caring for a 65-year-old male patient who was admitted with pancreatitis with no prior medical history. The patient keeps getting out of bed to go to the bathroom despite being repeatedly told to call for assistance. He has an IV infusion and nasogastric tube and is receiving opioids for pain. According to the Johns Hopkins Fall Assessment Tool, what is the patient's fall risk? A. High Risk B. Moderate Risk C. Low Risk D. Tool not Appropriate

B. Moderate Risk The patient is at moderate risk for falls: Age (60-69 years) - 1; Fall history - 0; Elimination (urgency or frequency) - 2; Medications (opioids) - 3; Patient care equipment (IV infusion and nasogastric tube) - 2; Mobility (requires assistance for mobility) - 2; Cognition (impulsivity/poor safety judgment) - 2 = 12 points;

The nurse is caring for an 85-year-old female patient who was admitted with constipation. The patient has a history of hypertension controlled with medications. She is alert and oriented, is receiving laxatives, has an IV infusion, and is ambulatory without assistance. According to the Johns Hopkins Fall Assessment Tool, what is the patient's fall risk? A. High risk B. Moderate risk C. Low risk D. Tool not appropriate

B. Moderate risk The patient is at moderate risk for falls: Age (80+ years) - 3; Fall history - 0; Elimination - 2 (incontinence); Medications (laxative and antihypertensive) - 5; Patient care equipment (IV infusion) - 1; Mobility - 0; Cognition - 0 = 11 points. Moderate risk is 6-13 points.

What question should the nurse ask to assess a patient's understanding of the risks related to poisonous substances? A. Do you have injuries that place you at risk for drowsiness? B. Do you know why you take your current set of medications? C. Are separate cutting surfaces used for cutting raw fish and meats? D. Do you have any safety concerns at home or work?

C. Are separate cutting surfaces used for cutting raw fish and meats? Asking about separate cutting surfaces for meat and fish assesses the patient's understanding of food safety and the prevention of food poisoning.

A patient has been admitted after falling at home and breaking an arm. When asked about the trip and fall hazards in the home, the patient states the home has hardwood flooring and area rugs in the main rooms. What additional question should the nurse ask to ensure the flooring is safe? A. Do you have nightlights in all your hallways? B. Are there handrails on the stairs? C. Do the area rugs have rug pads underneath them? D. Is there adequate lighting by the stairs?

C. Do the area rugs have rug pads underneath them? It is essential to ascertain if the area rugs in the patient's home have non-slip rug pads beneath them.

The nurse is caring for a 68-year-old female patient who recently underwent colon surgery. The patient is awake and alert. She has a saline lock and is receiving oral pain medications. The patient is ambulatory and able to push up to get out of the chair easily. According to the Hendrich II Fall Risk Model, what is the patient's fall risk? A. High risk B. Moderate risk C. Low risk D. Tool not appropriate

C. Low risk The patient is a low risk for falls: Confusion - 0; Depression - 0; Altered elimination - 0; Dizziness - 0; Gender - 0; Any antiepileptic agents - 0; Any benzodiazepine medications - 0; Get Up & Go Test - 1 = 1.

The nurse is caring for a 50-year-old male patient with a bowel obstruction. The patient has orders to be out of bed in a chair. He is alert and oriented with no prior medical history. The patient has an IV and nasogastric tube. According to the Morse Fall Scale, what is the patient's fall risk? A. High risk B. Moderate risk C. Low risk D. Tool not appropriate

C. Low risk The patient is a low risk for falls: History of Falls - 0; Secondary diagnosis - 0; Ambulatory aid - 0; IV/Heparin lock - 20; Gait/transferring - 0; Mental status - 0 = 20 points

To assess the patient's risk of exposure to biohazards in the home, what question should the nurse ask? A. Do you have air conditioning? B. What recreational activities do you engage in? C. Is there adequate outside lighting? D. Do you or does anyone in the home use hypodermic needles?

D. Do you or does anyone in the home use hypodermic needles? Asking about hypodermic needles helps the nurse identify the patient's risk for exposure to biohazards, as used needles may be contaminated with blood and infectious microorganisms.

Which is a patient-related fall risk hazard? A. Wound drain B. Floor surfaces C. Intravenous access D. Incontinence

D. Incontinence Incontinence is a patient-related fall risk hazard.

The Get Up & Go Test is part of what fall risk assessment tool? A. The Johns Hopkins Fall Assessment Tool - Category 1 B. The Johns Hopkins Fall Assessment Tool - Category 2 C. The Morse Fall Scale D. The Hendrich II Fall Risk Model

D. The Hendrich II Fall Risk Model The Get Up & Go Test is part of the Hendrich II Fall Risk Model.

A nurse is teaching a new nurse about the difference between the Johns Hopkins Fall Assessment Tool and the Morse Fall Scale. Which statement indicates the nurse understood the teaching? A. The Morse Fall Scale contains more items than the Johns Hopkins Fall Assessment Tool. B. The Morse Fall Scale solicits information on the patient's age and gender, while the Johns Hopkins Fall Assessment Tool does not. C. Neither tool solicits information regarding the patient's prior history with falling. D. The Johns Hopkins Fall Assessment Tool solicits information about the patient's medications and elimination issues, while the Morse Fall Scale does not.

D. The Johns Hopkins Fall Assessment Tool solicits information about the patient's medications and elimination issues, while the Morse Fall Scale does not. The Johns Hopkins Assessment Tool solicits information about the patient's medications and elimination issues, while the Morse Fall Scale does not.

Match the fall risk assessment method with the appropriate description. (Matching) ________- Seven-item assessment tool used in hospitals ________- Six-item assessment tool used in acute care and long-term settings ________- Eight-item assessment tool used in acute care settings A. Johns Hopkins Fall Assessment Tool B. The Hendrich II Fall Risk Model C. Morse Fall Scale

Johns Hopkins Fall Assessment Tool- Seven-item assessment tool used in hospitals Morse Fall Scale- Six-item assessment tool used in acute care and long-term settings The Hendrich II Fall Risk Model- Eight-item assessment tool used in acute care settings