Module 6

You are admitting Mr. Jones, a 64-year-old patient who had a right hemisphere stroke and a recent fall. The wife stated that he has a history of high blood pressure, which is controlled by an antihypertensive and a diuretic. Currently he exhibits left-sided neglect and problems with spatial and perceptual abilities and is impulsive. He has moderate left-sided weakness that requires the assistance of two people and the use of a gait belt to transfer to a chair. He currently has an intravenous (IV) line and a urinary catheter in place. What factors increase his fall risk at this time?

Takes antihypertensive and diuretics History of recent fall Neglect, spatial and perceptual abilities, impulsive Requires assistance with activity, unsteady gait IV line, urinary catheter

Which action by the home health care nurse indicates effective resource utilization?

Teaching the client about risks, benefits, and costs in care

A patient has recovered from seizures in a postoperative ward. How does the nurse ensure continued safety of the patient?

The call light and intercom should be kept near the patient. The side rails of the bed should be raised.

Besides a physical assessment, what should the nurse evaluate when visiting a home health care client?

The client's ability to use the telephone The client's ability to transfer to the toilet The client's ability to manage personal hygiene

A patient who has been involved in a fire accident wishes to use a fire extinguisher for future protection. What does the nurse teach the patient about using a fire extinguisher?

The fire extinguisher should be used only when a fire is confined to small areas.

A patient is confused and has become violent after recovering from a seizure episode. How does the nurse reorient this patient and provide further care?

The nurse answers the patient's questions. The nurse explains what happened.

Which measure should the nurse take while restraining a patient using a vest strap?

Tie the straps with a quick-release knot

The nurse asks an elderly patient to get out of the bed slowly, sit, and then stand up to prevent orthostatic hypotension. What is the purpose of giving these instructions to the patient?

To avert falls from blood pressure changes

The senior nurse is teaching a group of nursing students about the prevention of hospital fires. What activities should be performed during a fire?

Turn off sources of oxygen. Close all doors and windows. Use fire extinguisher.

The nurse is teaching a group of parents about safety measures for toddlers. Which instructions should the nurse give to the parents regarding medication safety?

Use child locks for medication cabinets Keep the medications on a high shelf Place childproof caps on all of the bottles

A 54-year-old woman is poor and suffering from tuberculosis. It has been found that other people with tuberculosis live in her area. What should the nurse include in her assessment of the community?

Water and sanitation facilities Economic status Transportation

An interdisciplinary team is evaluating the hospital's care of patients admitted with a myocardial infarction (heart attack) compared to national standards. The team analyzes the hospital's clinical indicator, which would be: (Select all that apply.)

aspirin order within 24 hours of discharge. patient teaching related to stopping smoking completed prior to discharge. beta blocker administered upon arrival.

The nurse instructor is teaching a group of student nurses about precautionary measures to be taken during radiation therapy. Which statement made by the student nurse indicates the need for further teaching?

"The nurse should always stand to the side of the radiation source."

A nurse is told in hand-off report that a patient opens eyes spontaneously, is confused but able to answer questions,and demonstrates purposeful movement to painful stimuli. What does the nurse calculate the patient's Glasgow Coma Scale to be?

13

Which of the following occurrences would be classified as a sentinel event?

A nurse assisting with the delivery of twins places the "Twin 1" name tag on the second-born twin, causing the first-born twin to undergo surgery that was scheduled for the other twin.

A 62-year-old woman is being discharged home with her husband after surgery for a hip fracture from a fall at home. When providing discharge teaching about home safety to this patient and her husband, the nurse knows that:

A safe environment promotes patient activity.

The nurse is teaching a group of parents about accidental poisoning. What would be the effects of lead poisoning in a child?

Adverse effects on child's growth Learning and behavioral problems Adverse effects on a child's nervous system

A couple intends to take their 5-year-old child for a long ride in a car. What advice does the nurse provide to this couple?

Advise the couple of the need for an appropriate car seat for this child.

A community health nurse is assessing the population of a specific community. She wants to identify people who are at risk of health problems. Which individual is a member of a vulnerable group?

An elderly, homeless immigrant

A new nurse is caring for an uncooperative patient who has undergone cardiac bypass surgery and needs restraints applied. Which action by a new nurse needs correction?

Applying vest restraint

The nurse works in the x-ray unit of a hospital. What guidelines should she follow with respect to the patient's safety?

Ask the patient to wear lead aprons when in the radiation zone. Limit the patient's time spent near the source of radiation. Make the distance from the source as maximum as possible.

The nurse is working with the county health department on a task force to fully integrate the goals of Healthy People 2020. How does the nurse determine which goals need to be included or updated?

Assesses the health care resources within the community Assesses the existing health care programs offered by the county health department Compares existing resources and programs with Healthy People 2020 goals

A parent calls the pediatrician's office frantic about the bottle of cleaner that her 2-year-old son drank. Which of the following is the most important instruction the nurse gives to this parent?

Call the poison control center.

A patient using a charcoal grill inside the garage presents to the emergency room with dizziness, drowsiness, and nausea. These assessment findings would be consistent with which type of poisoning?

Carbon monoxide poisoning

The nurse considers a company's financial implications as well as the employees' health concerns while working with the business owners to achieve safety goals for the workers. What is the role of the nurse at this level?

Case manager

The nurse presents data and statistical analysis reports to support outcome findings for the community. Which attribute is the nurse exhibiting?

Commitment to quality improvement

How does the nurse support a culture of safety?

Completing incident reports when appropriate Completing incident reports for a near miss Communicating product concerns to an immediate supervisor

The nurse is giving a seminar at a senior citizen center about the leading cause of injury in older adults. Which is the most important topic that the nurse should discuss with the older adults?

Complications from falls

A nurse works in a psychiatric unit. The nurse understands that the use of restraints may be useful for ensuring patient's safety. Which complications should the nurse be aware of when using physical restraints?

Compromised circulation Incontinence Pressure ulcers

To ensure the safe use of oxygen in the home by a patient, which of the following teaching points does the nurse include?

Do not use electrical equipment around oxygen. Special precautions may be required when traveling with oxygen Smoking is prohibited around oxygen.

How does the community health nurse perform a windshield survey of a community?

Drive or walk through the community

A patient who is a chronic smoker suffers a cerebrovascular accident. On assessment, the nurse learns that gait and vision are normal, but the patient is anxious and has a fear of falling. How does the nurse help the patient in managing anxiety?

Establish a therapeutic relationship with the patient. Encourage the use of effective coping skills.

Vulnerable populations of clients are those who are more likely to develop health problems as a result of:

Excess health risks, limits in access to health care services, and dependency on others for care

The employee health nurse identifies the risk for injury due to contact with a hazardous chemical in a large chemical factory. Who should the nurse include in the process of determining health-related goals for the employees?

Factory workers

A community nurse plans to perform health checkups at a long-term care facility. On visiting the convalescent home, the nurse learns that many of the residents suffer from dementia. What interventions can the nurse take that might be helpful?

Foster human dignity. Protect the client's rights in all aspects. Train caregivers on proper feeding and dressing.

Which factor will the nurse evaluate when assessing an elderly patient using the Morse Fall Scale?

Gait Pattern

Before applying a safety reminder device (SRD), the nurse must:

Get a physicians order

The nurse is assisting a patient who is having an examination of the female genitalia. What action by the nurse is best?

Get provider, assist patient into Lithotomy position

The nurse is using the Hendrich II Fall Risk Model to assess the risk of falling in an elderly patient. Which factors will the nurse evaluate using this tool?

Get-Up-and-Go test Use of benzodiazepines

In a pediatric ward, one of the newborns died of sudden infant death syndrome (SIDS). What nursing measure lowers the risk of death due to SIDS?

Having the baby sleep on its back

A nurse has been transferred from a hospital-based occupation to a population-based public health program. What are the key aspects of population-based programs which the nurse has to understand?

Health protection Health promotion Disease prevention

A nurse works in a community with a high prevalence of cancer. What nursing interventions would be helpful in reducing cancer-related morbidity at the community level?

Help people quit smoking. Motivate female clients to go for annual Pap smears.

What are the responsibilities of a community-based nurse as a client advocate in assisting clients with the use of health services?

Help the client make informed decisions. Help the client reach out to appropriate authority. Help the client in specific service requests and appropriate follow-up.

A client is suffering from leukemia and is in the terminal stage. The client has opted for a service that provides palliative care at home. Which service has the client selected?

Hospice

The nurse works in a nursing home. What are the common causes of death in the elderly population that the nurse should be aware of?

Hypothermia Heat stroke Falls

A nurse is working in a community clinic. Which population groups are at high risk of developing diseases?

Immigrants Homeless people People in abusive relationships

A community nurse in a diverse community is working with health care professionals to provide prenatal care for underemployed and underinsured South African women. Which overall goal of Healthy People 2020 does this represent?

Increase life expectancy and quality of life and eliminate health disparities

A patient has accidently consumed kerosene. What nursing intervention complicates the patient's condition further?

Inducing vomiting

The nurse manager clarifies that "safe hospital environment" implies that in the hospital setting people will be free from:

Injury

A nonprofit organization that distributes to governmental agencies, the public, business, and health care professionals knowledge related to health care for the purpose of improving health is the:

Institute of Medicine.

The nurse has used restraints for a disoriented patient. What reasons should the nurse give to justify the use of restraints?

It helps to reduce the risk of patient injury from falls. It prevents the patient from removing IV infusions. It helps to reduce the risk of injury to others by the patient.

A patient who works in a coal mine is referred to an occupational health center. Which services are provided to ensure the safety of the patient?

It provides services for health promotion, and accident and illness prevention.

A patient sustained minor burns in a fire at home. After stabilizing the patient, the nurse asks the patient to obtain a fire extinguisher at home. What instructions does the nurse provide to the patient?

It should be inaccessible to the children. It should be placed on each level near an exit. It should be placed in clear view. It should be kept away from stoves and heating appliances.

When the nurse ambulates with a patient who has left-sided weakness, what actions should the nurse take?

Keep the leg nearest the patient behind the patient's knee. Use a gait belt

A community nurse finds that a couple is unhappy because of financial constraints. In addition, the husband performs some cultural rituals that are against the wife's cultural beliefs. The wife wants a divorce. What should a community nurse do?

Learn more about the culture of the wife and the husband and help them reach appropriate decisions.

An 85-year-old man has come in for a physical examination, and the nurse notices that he uses a cane. When documenting general appearance, the nurse should document this information under the section that covers:

Mobility

An elderly couple visits the hospital for regular health check-ups. The woman, 67 years old, has been diagnosed with dementia. She lives with her husband, who is 75 years old. He is a hypertensive client and is on antihypertensive drugs. What interventions should the nurse perform for the client to help him manage hypertension?

Monitor blood pressure and weight. Educate about nutrition and dietary modifications. Educate about antihypertensive drugs and their side effects Promote lifestyle changes.

A community-based nurse plans to assess the health care needs of a particular community to ensure improved delivery of health care. How should the nurse assess the health care needs of this community? Multiple selection question

Monitor health status Collect data systematically Access available health information

The nurse notices a fire in a patient's room. What should be the nurse's first intervention?

Move the patient to a safe area

What is the initial nursing intervention for a patient who has inhaled poisonous fumes?

Move the patient to obtain fresh air

In a public health clinic, a nurse notices bruises on the back of a married, unemployed woman and injuries to her genitalia and breasts. The client appeared frightened when her husband was around. What should the nurse do?

Notify the relevant authority. Discuss her findings with the woman when her husband is not around.

A nurse is assessing a patient with an uncoordinated and shuffling gait. The patient also has a stooping posture. What are the assessment activities that the nurse performs on this patient?

Observation of body alignment Measuring the range of motion Appraising the patient's home for hazards Observation of posture

When performing a neurologic assessment of a male patient, a nurse discovers that shouting and shaking are necessary to arouse the patient enough to assess his neurologic status. After the patient answers questions about who he is and squeezes the nurse's hand as requested, he returns to "sleep." How does the nurse document this patient's level of consciousness?

Obtunded

While recording in a patient's medical record, the nurse notices that a patient's Hematest results are positive. This finding means that there is(are):

Occult blood in his stool.

A nurse is teaching about the types of care that are included under the umbrella of community health care. Which types of care should the nurse include?

Parish health care School health care Palliative care

A nurse works in a psychiatric unit. The nurse understands that the use of restraints may be useful for ensuring patient's safety. Which patients would need a temporary restraint?

Patients who repeatedly fall Patients who try to remove medical devices Confused patients

A patient states, "Whenever I open my mouth real wide, I feel this popping sensation in front of my ears." To further examine this, the nurse would:

Place a finger on his temporomandibular joint, and ask him to open and close his mouth.

A client is diagnosed with gastroenteritis. The nurse finds that the client is an unemployed immigrant and doesn't understand the language properly. What should the nurse do to help this client? .

Plan a visit to the client's house. Try to find a language translator for the client for better communication during the next session.

While examining a 48-year-old patient's eyes, the nurse notices that he had to move the handheld vision screener farther away from his face. The nurse would suspect:

Presbyopia

The local health department received information from the Centers for Disease Control and Prevention that the flu was expected to be very contagious this season. The nurses set up flu vaccine clinics in local churches and senior citizen centers. This activity is an example of which level of prevention?

Primary

The school nurse is teaching children oral hygiene and prevention of cavities. The nurse is focusing on which level of health care?

Primary prevention

Which environmental factor should the nurse consider while assessing the risk of falls in an elderly patient?

Proper illumination

The nurse found a 68-year-old female patient wandering in the hall. The patient says she is looking for the bathroom. Which interventions are appropriate to ensure the safety of the patient?

Provide scheduled toileting during the night shift. Keep the pathway from the bed to the bathroom clear. Leave a night light on in the bathroom

In a trauma unit a patient who was injured in a traffic accident begins having seizures. How does the nurse position this patient to prevent traumatic injury due to seizures?

Raise the side rails of the bed. Clear the surrounding area of all furniture.

The new nurse is caring for a patient who is experiencing a seizure. Which action taken by the new nurse needs correction?

Restraining the patient with his or her hands

A patient reports she has shortness of breath and peripheral edema. Under which category does the nurse document these data?

Review of systems

What should be the first nursing intervention if a child has accidently sprayed furniture polish into both eyes?

Rinse both eyes with water

The nurse assesses a patient in a Posey safety reminder device (SRD) for which problem(s) that may increase because of use of SRDs? (Select all that apply.)

Risk for impaired circulation Incontinence Risk for skin impairment Immobility

The parish nurse arranges an eye check-up camp for community members to detect glaucoma. What is the goal of this program?

Secondary prevention

Which of these are included in an assessment of the general appearance?

Skin Color

While conducting surveillance for complications of cigarette smoking, a nurse found a high risk of lung cancer in two clients in a small community of 150 people. As a community health nurse what should she do?

Study the incidence of lung carcinoma. Act as a change agent in the community. Help the clients who are at high risk in making decisions about further care. Discourage the people of the community from smoking cigarettes.

In which position should the nurse place an infant to prevent sudden infant death syndrome?

Supine position

During resuscitation efforts, a provider states, "I need to give a 1.5 mg/kg bolus of lidocaine because the patient is in ventricular tachycardia." The nurse responds, "I have a lidocaine bolus equal to 1.5 mg/kg." This communication model is known as:

check back

Patients with heart failure have extended lengths of stay and are often readmitted shortly after they have been discharged. To improve quality of care, a type of "road map" that included all elements of care for this disease and that standardized treatment by guiding daily care was implemented. This road map is referred to as a(n):

critical pathway.

The nurse should wear gloves for which of these examinations?

palpation of the mouth and tongu

The surgical team arrives in the operating room and one member states, "Everyone stop. Let's identify the patient and operative site. Now does anyone have any questions or concerns?" This process is known as:

time-out