Chapter 27 PrepU

The community health nurse is talking with four clients. Who does the nurse identify that would most benefit from teaching about alcohol and drug use?

19-year-old male college student majoring in physics Explanation: Young adults, particularly those who just became emancipated from parental supervision, are at the highest risk for alcohol and drug use. Other clients may have other safety risk factors, but are not at a proportionately higher risk for alcohol and drug use.

The home health nurse is performing fall risk assessments. Which client is identified by the nurse as being a high risk for falls? Select all that apply.

A client taking benzodiazepines A client with poor lighting in the home A client with scatter rugs throughout the home A client with a history of previous falls

A school-age child is admitted to the emergency room with a possible concussion following a collision when playing football. After the collision, the parents state that he was "knocked out" for a few minutes before recognizing his surroundings. What is the priority assessment when the nurse first sees the client?

Assessment of vital signs and respiratory status

A nurse is educating parents of preschoolers on appropriate safety measures for this age group. What might be a focus of the education plan?

Childproofing the house

The nurse is caring for a client with dementia who lives alone at home and has begun wandering. What is the appropriate nursing response when the caregiver states, "What can I do? I am afraid my spouse is going to get lost."

"Consider the Alzheimer's Association 'Safe Return' program."

A nurse is caring for a client who is receiving an intravenous therapy through an IV pump. Which intervention should the nurse implement to ensure electrical safety?

Obtain a three-prong grounded plug adapter.

What is the primary role of the nurse in the care of clients who experience domestic violence?

Providing prompt recognition of the potential or actual threat to safety Explanation: 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.

A nurse responds to the call bell and finds another nurse evacuating the client from the room, which has caught fire. Which action should the nurse take?

Pull the fire alarm lever.

A nurse is preparing discharge education for a client with a newborn baby. What is the highest priority item that must be included in the education plan?

Restrain the baby in a car seat.

The nurse has completed a comprehensive assessment of a client who has been admitted to the hospital experiencing acute withdrawal from alcohol. What nursing diagnosis would provide the clearest justification for the use of physical restraints during this client's care?

Risk for Injury Related to Agitation Explanation: The client's risk of self-injury or injury to others is the justification for restraint use. Restraints are not normally used to address noncompliance or chronic confusion unless there is a consequent safety risk. Impaired bed mobility is not a justification for restraints.

The nurse is creating a plan of care for the older adult who has multiple medications and a difficult time reading medication labels due to poor eyesight. What is the most appropriate nursing diagnosis to include in this client's plan of care?

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

The nurse is caring for an 80-year-old client who was admitted to the hospital in a confused and dehydrated state. After the client got out of bed and fell, restraints were applied. She began to fight and was rapidly becoming exhausted. She has black-and-blue marks on her wrists from the restraints. What would be the most appropriate nursing intervention for this client?

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

The nurse is performing an assessment on an older adult. From which data does the nurse deduce that the client is at high risk for falls in the home? Select all that apply.

Takes furosemide daily Admits to drinking wine through the evening Has history of diabetic neuropathy Explanation: The acronym DAME (Drug/alcohol use, Age-related physiologic status, Medical problems, Environmental) assists the nurse to asses fall risk at home. The diuretic furosemide may cause the client to fall during frequent and possibly urgent trips to the toilet. Furosemide may also cause volume depletion and dizziness in standing. Diabetic neuropathy contributes to falls because of loss of normal sensation in feet and lower extremities. Consuming alcohol contributes to loss of balance, volume depletion and urinary urgency. Living on one floor and performing regular exercise describe positive characteristics for fall prevention.

The school nurse is preparing a presentation about safety promotion for middle school students. Which topic should the nurse plan to include?

The importance of consistent seat belt use

A nurse is completing an intake assessment. The nurse notes that an older adult male client appears to have bruises in varying stages of healing. Which action by the nurse indicates an understanding of her responsibilities?

The nurse should question the client about the source of the bruises.

A nurse is preparing to file a safety event report after a client experienced a fall. Which statement is correct regarding the filing of a safety event report?

The nurse should record the incident in the client's medical record and fill out a safety event report separately.

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

Use night-lights in bedrooms and bathrooms.

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

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

A client went missing from a long-term care facility and an emergency code was called. After a search of 1 hour, the client was discovered in a utility room that should have been inaccessible. When responding to this event, staff should:

fill out an incident report, with the goal of preventing a similar event in the future.fill out an incident report, with the goal of preventing a similar event in the future. Explanation: Incident reports are primarily used to facilitate improvements, not to determine culpability. A client's health record requires skill to document the necessary behavior and results and allows for adapting nursing care planning; a client health record must not discuss aspects particular to the incident report or facility issues. Holding a meeting will likely be necessary or helpful, but does not replace the need to document the event in the form of an incident report.

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

have a meeting place outside the home.

A client has been discharged from the hospital after being treated for a myocardial infarction. The client has been asked to evaluate the care received by completing the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS). The results of this survey may affect:

the amount of money the hospital receives from the Centers for Medicare & Medicaid Services.

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

Avoid unattended baths for the toddler.

The nurse overhears an older adult client's son talking to her in a very aggressive and violent way. When the nurse walks into the room, the son changes and speaks kindly to his mother and the health care providers. What should the nurse do about this observation?

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

The nurse manager is reviewing the QSEN quality and safety competencies for nurses. Which competencies are included in this initiative? Select all that apply.

Client-centered care Teamwork and collaboration Quality improvement (QI) The Quality and Safety Education for Nurses (QSEN) project has been designed to provide a framework for the knowledge, skills, and attitudes necessary for future nurses. The six competencies include client-centered care, teamwork and collaboration, evidence-based practice, quality improvement, safety, and informatics. Requirements for foreign-educated nurses and the establishment of clinical career ladders are not explicit focuses of the QSEN competencies.

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

Dangling blind cords Explanation: As babies gain neurologic and musculoskeletal functions, they learn and explore by pulling objects to themselves and placing almost everything in their mouths. Cords, tablecloths, plastic bags, bottles, and cans are tempting, dangerous objects that caregivers must strive to keep out of reach.