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When performing fall risk assessments, the nurse understands that which of these clients is most at risk for falls

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

A nurse is caring for an 18 month-old boy status post a tracheostomy. He is recovering well and wanting to be more active. The nurse selects a toy from the playroom for him to play with. Which toy is most developmentally appropriate?

A rocking horse

Which safety tip could the nurse give to parents to help decrease the risk of the leading cause of injury or death in children 1 to 4 years of age?

Always provide close supervision for young children when they are in or around pools and bathtubs."

The nurse overhears an older 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. Correct

What is the most common cause of unintentional injury death in the United States?

Automobile accidents

Which factors have been identified as primary causes of falls? Select all that apply.

Benzodiazepine use • Poor lighting • Environmental hazards • History of previous falls

A nurse is treating an adolescent who swallowed drain cleaner on a dare from his classmates. Which interventions would the nurse perform related to this situation? (Select all that apply.)

Dilute with milk or water. • Contact physician or primary care provider.

A child is playing soccer and is involved in a head collision with another player. Which assessment findings should the nurse be alert to that may indicate a concussion? (Select all that apply.)

Drowsiness • Vomiting • Headache

Unintentional injuries are a major cause of disability and death in the United States. For adults, where do unintentional injuries fall on the list of leading causes of death?

Fifth

An older adult woman in a long-term care facility has fallen and sustained several injuries. Which of her injuries would be the most serious fall-related injury?

Fractured hip

When educating families on fire safety in the home, which information is important for the nurse to emphasize?

Have a meeting place outside the home in case of fire.

The leading causes of death for children ages 1 to 4 in the United States, particularly in southwestern states, is drowning. How can the nurse assist in lowering this statistic?

Implement drowning-prevention strategies.

The unlicensed personnel tells the nurse that a client is very confused and trying to get out of bed without assistance. What is the appropriate action by the nurse?

Initiate use of a bed alarm

A nurse working in a long-term care facility institutes interventions to prevent falls in the older adult population. Which intervention would be an appropriate alternative to the use of restraints for ensuring client safety and preventing falls

Involve family members in the client's care

The nurse is able to help promote safety and prevent injury by identifying which factors that have a direct impact on client safety? Select all that apply.

Mobility • Developmental level • Communication ability

A school nurse is teaching a group of adolescents about safe driving. What behaviors should the nurse encourage in order to help prevent motor vehicle accidents? (Select all that apply.)

Never text while driving. • Obey the speed limit. • Always wear a seat belt. • Limit the number of other adolescents in the car.

Which level of health care provider may make the decision to apply physical restraints to a client?

Nurse practitioner

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.

A nurse is teaching a community group about bicycle safety. Which statement should be included when creating a teaching plan regarding bicycle safety?

Parents are effective role models for children when they also wear helmets while riding."

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

Providing prompt recognition of the potential or actual threat to safety

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 is caring for a young child in the hospital that is being discharged home with his grandmother who has guardianship. When performing a risk assessment, the nurse identifies that his grandmother has one other adult living with her to help with the child, because the grandmother has congestive heart failure and diabetes mellitus. In addition, the financial situation is poor and she cannot afford to buy safety devices to safe proof the house. What nursing diagnosis is most appropriate for this child based on these findings?

Risk for poisoning related to medications in unlocked cabinets

The nurse is caring for an 80-year-old patient who was admitted to the hospital in a confused and dehydrated state. After the patient 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 patient?

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

The nurse needs to plan the interventions necessary to reduce fall risks for the older adult clients at her facility. Which is the strongest indicator that a client is at risk for falls?

The client has fallen before

The acute care nurse is caring for a client who is at risk for falling. Which desired outcome is most appropriate for this client?

The client will not experience a fall and remains free of injury.

A nurse caring for a confused client who is not allowed to get out of bed asks the physician for an order for restraints. Which of the following are guidelines for the use of restraints on clients? Select all that apply.

The client's family must be involved in the decision and plan of care. • Alternatives to restraints and less restrictive interventions must have been implemented and failed. • The benefit gained from using a restraint must outweigh the known risks for that client.

A nurse follows the universal patient compact principles for partnership when providing care for patients. Which nursing action does not reflect this philosophy?

The nurse makes health care decisions for a patient who is uncooperative.

The nurse is assessing an adolescent with an annual physical. The mother reports that she has noticed a change in the child's behavior lately including mood swings, withdrawal from the family, and failing school grades. The mother does not know what to do and asks the nurse for guidance. What is the most appropriate guidance from the nurse?

These could be signs of substance abuse. Open communication and a referral to a counselor that specializes in substance abuse would be beneficial."

Which topic should a public health nurse emphasize when educating older adults on reducing their risk of poisoning

keeping medications in clearly labeled containers

A school-aged child is admitted to the Emergency Room with the diagnosis of a 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 patient?

Assessment of vital signs and respiratory status

What is the most important safety concept that a nurse should include in the teaching plan for a family with a newborn infant in the household?

Avoid stuffed animals and blankets in the crib.

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.

Which statement should the nurse include in the teaching plan for a family that is learning about fire safety?

Most people who die in home fires die from inhalation and not from burns

A school nurse is providing information to a group of older adults during Fire Prevention Week. Which statement is correct regarding fires in the home?

Most people who die in house fires die of smoke inhalation, rather than burns.

What best describes the nurse's role in disaster preparedness?

Multiple roles including triage and the distribution of resources

the nurse is creating a plan of care for the older adult that 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

Which reason best explains why adolescents behave in an unsafe manner despite knowledge of a particular activity's risk?

Social pressure

A nurse is performing safety assessments in a health care facility. Which statements reflect considerations a nurse should keep in mind when assessing a client for safety? Select all that apply.

Some people are more prone to have accidents than others. • A medication regimen that includes diuretics or analgesics places an individual at risk for falls. • A person with a history of falls is likely to fall again.

A nurse is filing a safety event report for an older adult client who tripped and fell when getting out of bed. Which action exemplifies an accurate step of this process?

The nurse details the client's response and the examination and treatment of the client after the incident.

A 14-year-old boy is in the clinic for his well-child exam. When the client asks his mother if she has any questions for the practitioner, she states "He sleeps so much. I am worried about how lazy he is." What does the nurse know to be true about sleep in adolescents?

Trying to balance too many activities can result in sleep deprivation.

The Joint Commission advises that health care workers use physical restraints on clients only as a last resort. Which alternative methods of restraint are recommended?

Use a large plant or piece of furniture as a barrier to limit wandering from designated area. • Conceal tubing necessary for care. • Use simple, clear explanations and directions. • Reduce stimulation, noise, and light.

A nurse is teaching parents about Internet safety for their children. Which of the following are recommended guidelines for Internet use? Select all that apply.

Use filtering software to block objectionable information. • Investigate any public chat rooms used by the children. • Be alert for downloaded files with suffixes that indicate images or picture

Which statement indicates that a family understands the teaching that has been provided by the nurse related to car seat safety for their 9-month-old infant?

We place our baby in a rear-facing car seat in the back seat of the ca

A staff development nurse is providing an in-service to a group of nurses on the use of restraints in health care facilities. What is an example of a chemical restraint?

a dose of an antipsychotic

An 18-year-old is brought to the emergency department with a head injury. The nurse knows that adolescents are vulnerable to injuries related to:

automobile accidents.

A school nurse is aware of poisoning risks in the adolescent population. Poisoning in this age group is most often related to

experimentation with drugs and inhalants.

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?

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

One of the leading causes of death in the United States, particularly in southwestern states, is drowning. How can the nurse assist in lowering this statistic?

implement drowning-prevention strategies.

During a course on terrorism, a group of emergency room nurses learns about terrorists who use bombs or other explosives to inflict injury on numerous people and cause multiple fatalities. This is an example of:

mass trauma terrorism.