Question 1

A nurse working in an acute care facility's emergency department should recognize which of the following client reports as being most suspicious of a terrorist attack?

Accepted Answer

An unusual increase in the number of people seeking care,especially with fever,respiratory,or gastrointestinal complaints,is a classic indicator of such an event.While the other options present possible indicators,there are other possible reasons for the incidents.

Question 2

Which of the following statements indicates that the client is at risk for an electrical shock at home?

Accepted Answer

The "third" prong is used to ground the piece of equipment.Improperly grounded equipment can cause electrical injury.

Question 3

The nurse is conducting an admission interview and assessment on a cognitively impaired,uncooperative client for the risk for injury.Which of the following options will most likely provide the information to confirm the diagnosis?

Accepted Answer

In many cases family members are important resources in assessing a client's fall risk.Families often are able to report on the client's level of confusion and ability to ambulate.

Question 4

The nurse recognizes that the greatest benefit of engaging the mother of two small children into a discussion about child-proofing her home is that:

Accepted Answer

The client who is an active participant in reducing threats to safety becomes more alert to potential hazards.

Question 5

A nurse finds that an electrical cord has shorted out in a client's room,causing a fire.The nurse should do which of the following actions first?

Accepted Answer

The mnemonic RACE should be used to help remember to rescue or remove all clients in immediate danger,activate the alarm,confine the fire,and extinguish the fire

Question 6

Which of the following assessment findings is most critical in a client who is currently being restrained with mechanical wrist restraints?

Accepted Answer

While the use of any restraint may be associated with serious complications,including pressure ulcers,constipation,pneumonia,urinary and fecal incontinence,and urinary retention,the most serious are contractures,nerve damage,and circulatory impairment.The coolness of the client's hands indicates poor circulation and can result in permanent damage.

Question 7

The nurse recognizes which of the following clients is at greatest risk for an accidental death?

Accepted Answer

The adult experiencing a high level of stress is more likely to have an accident or illness such as headaches,gastrointestinal (GI)disorders,and infections.While the remaining options identify risks,they are not a high as that of the stressed adult.

Question 8

When discussing the new mother's pending discharge from the hospital,the nurse determines that additional client teaching needs to take place because of which of the following comments?

Accepted Answer

Newborns should not be placed in cribs with loose comforters,bumper pads,etc.The middle of the back seat is the safest place to put the infant car seat.Babies should not be placed on their stomachs with their mouth and nose in close proximity to the mattress,which is associated with sudden death syndrome.Lead paint on infant toys can lead to brain damage.

Question 9

The nurse is discussing a newly ordered diuretic with an older adult client who is home-bound.Which of the following suggestions has the greatest potential for minimizing the client's risk for injury related to urinary urgency or incontinence?

Accepted Answer

Nocturia and incontinence are more frequent in older adults.Give diuretics in the morning.While the other options may have value,they do not have an impact on the situation as directly as the administration of the medication.

Question 10

A confused client needs to have restraints to prevent him from pulling out his Foley catheter.Which of the following can the nurse delegate to the nursing assistive personnel?

Accepted Answer

Although the nursing assistive personnel can apply the restraints under the nurse's direction,they cannot document,evaluate,or take physician's orders.

Question 11

The nurse is discussing safety issues with the mother of three children.Which of the following statements has the greatest possibility for decreasing the potential for injury among the children?

Accepted Answer

Clients generally expect to be safe in their homes and health care settings.However,there are times when a client's view of what is safe does not agree with that of the nurse.For this reason,any assessment needs to include the client's understanding of his or her perception of risk factors.The remaining options are directed toward specific safety issues.

Question 12

Which of the following clients is at greatest risk for injury related to medical diagnoses and conditions?

Accepted Answer

This client is likely using diuretics that increase the frequency of voiding and result in the client having to use toilet facilities more often.Falls often occur with clients who have to get out of bed quickly because of urinary urgency.

Question 13

A client who is experiencing a generalized clonic-tonic seizure is at greatest risk for injury caused by:

Accepted Answer

During a fall,or as a result of muscle jerking,musculoskeletal injuries can occur.The fall is the most problematic since is occurs in the vast majority of the seizure events.

Question 14

A nurse caring for an elderly client who has had surgery and is in the hospital knows that the client is at high risk for developing a nosocomial infection.One of the most important things that the nurse can do to prevent this client from obtaining a nosocomial infection is to:

Accepted Answer

Antibiotics should be used appropriately to prevent resistant organisms.The best way to prevent nosocomial infections is to perform hand hygiene before and after each client encounter and after contact with contaminated objects.Isolation will not in itself prevent a nosocomial infection.Answer 4 will help prevent atelectasis,but not necessarily a nosocomial infection.

Question 15

The nurse is discussing measures to minimize the risk of injury from an automobile accident with an 83-year-old adult client who lives alone and claims to drive only to church,the doctor's office,and for groceries.Which of the following suggestions has the greatest potential for affecting this client's safety?

Accepted Answer

The nurse educates clients regarding safe driving tips (e.g. ,driving shorter distances or only in daylight,using side and rearview mirrors carefully,and looking behind them toward their "blind spot" before changing lanes).The other options,while not incorrect,may not be realistic or appealing to an independent client.

Question 16

The nurse and a mother of two small children are discussing child safety issues.Which of the following nursing interventions has the greatest potential for using collaboration to help ensure the children's safety?

Accepted Answer

Clients need to learn how to identify and select resources within their community that enhance safety (e.g. ,neighborhood block homes,local police departments,and neighbors willing to check on a client's well-being).The remaining options deal with individual aspects of a complete plan.

Question 17

A nurse in the emergency department (ED)of a community hospital notes that an unusually high number of clients have presented in the ED with flulike symptoms,abdominal pain,nausea,vomiting,bloody diarrhea,hematemesis and itching of the hands,forearms,and head.The nurse is concerned with bioterrorism,reports this to the supervisor,and suspects an outbreak of:

Accepted Answer

The symptoms of the clients all point to an endemic outbreak of anthrax.

Question 18

The nurse caring for an elderly client in the hospital notes on assessment that the client has a scald burn on her foot.On questioning the client,the nurse learns that the client scalded her foot when adding hot water from the tap to her bath while she was in the tub.The nurse should do which of the following?

Accepted Answer

Hot water from the tap should not have the potential to scald,because it is a safety hazard.The client had a plausible explanation for the incident without other signs to indicate abuse.There is no reason that the client should not be able to continue to take tub baths if the water temperature is within a safe range.The client has no other indications that she is in any danger of caring for herself;thus Answer 4 is not appropriate.

Question 19

When preparing a safety workshop for early teens (13 to 15 years old),the nurse recognizes that which of the following active strategy topics has the greatest potential for decreasing injuries in this population by affecting lifestyle changes?

Accepted Answer

To promote an individual's health,it is necessary for the individual to be in a safe environment and to practice a lifestyle that minimizes risk of injury.Active strategies are those in which the individual is actively involved through changes in lifestyle (e.g. ,wearing seat belts or installing outdoor lighting)and participation in wellness programs.Accidents involving automobiles account for the most substantial number of injuries and deaths among this population from among the options provided.

Question 20

A confused client on a ventilator was restrained to prevent him from pulling out his endotracheal tube.Which of the following could be a possible alternative measure that the nurse could use to avoid the use of the restraints?

Accepted Answer

A trained sitter can prevent the client from pulling out the endotracheal tube.The client is confused and does not understand.The endotracheal tube cannot be camouflaged effectively-the client feels it more than sees it.Because the client is confused,it may be very difficult to communicate relaxation techniques so that the client has an understanding.

Quiz 38: Client Safety