Chapter 27: Security

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."

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.

A client has presented to the emergency department after splashing a chemical in the eyes. When managing the injury, what should be included in the plan of care?

Flush the eyes with water for 10 minutes.

Which actions should the nurse perform to help prevent occupational safety hazards? Select all that apply.

Only operate equipment the nurse is familiar with. Use equipment only for the use for which it was intended. Use three-pronged electric plugs whenever possible.

The telehealth nurse receives a call stating that upon entering a family member's home, two people have been found semi-conscious with a bright cherry red skin color. They are reporting nausea and headache, and are unable to move. Which initial direction will the nurse provide?

Open doors and windows.

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 recognizes that assessment for sensory-perceptual alterations is a priority for which client?

an 84-year-old male with four recent driving violations

A nurse visits an older adult client at home and assesses the safety of the client's environment. Which article can be a threat to the client's safety?

area rugs kept on the stairs without carpet

A 17-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 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.

The nurse is working at a local elementary school. A mother arrives to pick up her 6-year-old son and has her 2-year-old daughter in tow. Based on the nurse's developmental knowledge of toddlers, which behavior would most concern the nurse?

the 2-year-old leaning against the screen of a window in a classroom

The nurse is assessing an adolescent with an annual physical. The parent reports noticing a change in the child's behavior lately, including mood swings, withdrawal from the family, and failing school grades. The parent 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 use. Open communication and seeing a counselor who specializes in substance use would be beneficial."

The nurse is caring for an adult client on prescribed bed rest who repeatedly attempts to get out of bed despite instructions to remain in bed. Which initial intervention is appropriate?

Assess for the need to urinate.

A nurse is providing instructions to the mother of a toddler regarding the prevention of burn injuries in the toddler. Which instruction is the priority to provide to the mother?

Keep coffee cups on the counter above the child's reach.

A nurse is teaching parents about Internet safety for children. Which actions 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 pictures.

The nurse is conducting a community education program on bike helmet safety. The nurse determines additional information is needed when a participant states:

"I should be able to fit two fingers between my chin and the chin strap."

The poison control nurse receives a call from the parent of a 2-year-old child. The parent states, "I just took a quick shower, and when I finished, I walked into the kitchen and found my child with an open bottle of household cleaner." What is the poison control nurse's appropriate response?

"Is your child breathing at this time?"

Which nurse would be at the highest risk of causing a hazardous situation?

A nurse who has worked 32 hours of overtime this week

The acronym RACE is commonly taught as a means for remembering priorities for action during a fire. The "A" in this acronym stands for which of the following?

Activate the fire alarm and notify the appropriate person.

The older client tells the nurse that the client needs to use the restroom. Which safety intervention must the nurse perform first?

Assess the need for assistance with ambulation.

A school-age 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 client?

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.

The nurse is teaching the caregiver of a school-age child about safety. Which teaching will the nurse include?

Buy protective sporting equipment.

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)

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

Dangling blind cords

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

Drowsiness Headache Vomiting

A client has been diagnosed with a glioblastoma and the care team has determined that this brain tumor is inoperable. Which aspects of the the client's subsequent care demonstrate adherence to the Quality and Safety Education for Nurses (QSEN) competencies? Select all that apply.

Each member of the care team uses the best available technology to organize and provide care. Nurses proactively identify threats to the client's safety that may occur as treatment is provided. The care team balances the best available evidence about glioblastoma treatment with the client's preferences. The care team meets with the client and family promptly to identify their preferences for treatment.

A health care provider orders extremity restraints for a confused client who is at risk for injury by pulling out her central venous catheter. What is the nurse's most appropriate action when carrying out this order?

Ensure that two fingers can be inserted between the restraint and the client's extremity.

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.

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

Implement drowning prevention strategies.

The unlicensed assistive personnel (UAP) 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.

An order for a waist restraint has been obtained for a client who is a threat to her own safety. The nurse should perform which action?

Insert a fist between the restraint and the client to ensure that her breathing is not constricted.

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

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 client in a long-term care facility has become increasingly unsteady. The nurses are worried that the client will climb out of bed and fall. Which measure would be a priority recommendation for this client?

Placing the client in a bed with a bed alarm

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

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.

The nurse is providing discharge teaching to the family of an older adult client. Which teaching will the nurse include to decrease the risk for electric shock?

Refrain from using extension cords.

The nurse on a medical-surgical unit notices smoke from a client's room. Upon entering, the nurse notes that the curtain in the room is on fire. What should be the nurse's first action?

Remove the client from the room.

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

A client who is enrolled in Medicare and who has been recovering in the hospital from a stroke has developed a pressure injury on the coccyx, an event that the Centers for Medicare & Medicaid Services (CMS) has identified as a "never event." The nurse should recognize what implication of this CMS designation?

The hospital must bear any costs incurred for treating the client's injury.

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 preparing to implement an order for the use of restraints to ensure a client's safety. Which statement accurately describes a guideline to follow?

Time-limit the use of restraints and release the client from the restraint as soon as he or she is no longer a risk to self or others.

Which factor is related to the highest proportion of falls in long-term care settings?

Toileting

The school nurse is educating 7th grade children about safety. Which recommendation is most appropriate for this age group?

Use protective sporting equipment

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

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

When educating a family on fire safety, it is important to:

have a meeting place outside the home.

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

keeping medications in clearly labeled containers

The nurse educator has just completed a lecture regarding older adults and hazards in the home. The nurse educator recognizes that the education was effective when the students state that common dangers in the home setting of an older adult include:

polypharmacy and use of multiple extension cords.