Question 1

The nurse has just placed a bed alarm for a client who is disoriented and has explained its use to the client and his family.Which statement by a family member indicates a need for further information related to fall prevention?

Accepted Answer

The statement indicates a misunderstanding that the bed alarm alone ensures safety, suggesting the family member might leave the client unattended, which is not advisable for fall prevention.

Question 2

The nurse is caring for an older adult client who is very confused and is also very thin.The healthcare provider has prescribed wrist restraints to help prevent the client from getting out of bed.Which is the priority for the nurse in applying the wrist restraints to this client?

Accepted Answer

The priority is to protect the client's skin integrity, especially since the client is very thin and at higher risk for skin breakdown. Padding the wrist bones before applying the restraint helps prevent injury and ensures the client's safety and comfort.

Question 3

The nurse is caring for four clients and knows that which client is at the highest risk for falls?

Accepted Answer

The client admitted for dehydration who is confused and sometimes combative is at the highest risk for falls due to confusion and combativeness, which can lead to poor judgment and increased risk of falling.

Question 4

The nurse is caring for a female client who has just completed taking a shower.The nurse notes that she is using her own hair dryer to dry her hair.Which is the nurse's best statement to the client concerning this possible safety issue?

Accepted Answer

The best statement is to ensure the safety of the electrical device before use, which is why option B is correct. It addresses the potential safety issue without outright banning the use of personal items, and it offers a solution by involving the maintenance department to check the safety of the hair dryer.

Question 5

The nurse has completed an assessment of an older adult client who lives with her son and his wife.The nurse observed some bruising on the client but no other signs of abuse.Which question by the nurse to the client would be most helpful in determining if abuse is occurring?

Accepted Answer

Asking directly about the cause of the observed bruises ("How did the bruises I noted on your wrists occur?") is the most direct and specific way to gather information that could indicate abuse. It addresses a specific concern (the bruises) and invites an explanation, which can then be assessed for consistency and plausibility.

Question 6

The nurse is caring for a client who is disoriented and confused.Which is the safest and least restrictive way to assist this client?

Accepted Answer

Dimming the lights and keeping the room quiet can help reduce sensory overload, which can be beneficial for a client who is disoriented and confused. This approach is non-restrictive and promotes a calm environment.

Question 7

While admitting an adult client for treatment of pneumonia,the nurse discovers that the client has been diagnosed with a seizure disorder.What safety precautions will the nurse put into place for this client? Select all that apply.

Accepted Answer

B) Suction equipment should be readily available in case of a seizure to help clear the airway if necessary. E) Padding the side rails and headboard of the bed with blankets can help prevent injury if the client has a seizure and hits these surfaces.

Question 8

The nurse is discussing safety precautions at home with the parents of an 8-year-old child diagnosed with a seizure disorder.Which play activity would the nurse recommend to this family?

Accepted Answer

Participating on a robotic team is a safe activity for a child with a seizure disorder as it involves minimal physical risk and can be done in a controlled environment.

Question 9

Which statement by an older adult client to the nurse would indicate that the client is being abused? Select all that apply.

Accepted Answer

- A indicates potential neglect regarding basic needs such as appropriate clothing.- B suggests neglect in personal hygiene care, which can lead to health issues.- C implies physical abuse and fear of retaliation from the abuser.

Question 10

The nurse has been caring for a client who had a tonic-clonic seizure in the hallway of the nursing unit.Which is the first action the nurse should do when the seizure has finished?

Accepted Answer

After a seizure, the first action should be to reassure the client, ensuring they feel safe and cared for, as they might be confused or disoriented.

Question 11

The nurse notices a fire at the end of the hall of a second-floor unit and recognizes that the clients will need to be evacuated out of the hospital.The nurse will use which carrying method to evacuate clients safely out of the hospital?

Accepted Answer

The answer of The nurse notices a fire at the...

Question 12

The home health nurse visits an older adult client's home prior to a client's discharge from the hospital to evaluate the home for any safety issues.Which situation if seen by the nurse would constitute the largest safety issue for this client?

Accepted Answer

The presence of a traditional bathtub in the house poses the largest safety issue for an older adult client, especially if they have mobility issues. It can increase the risk of falls and injuries while trying to get in or out of the bathtub. Options A and C are actually safety measures, and D, while potentially a sign of neglect, does not directly impact the client's physical safety in the same way.

Question 13

The nurse smells smoke and notes what appears to be a fire in the waste basket in the client's room.Which is the nurse's first action when the fire is noted?

Accepted Answer

The nurse's first action should be to ensure the safety of the client by assisting them out of the room to protect them from the immediate danger of the fire.

Question 14

The nurse must restrain a child and knows that a blanket restraint will be best for which child in the nurse's care?

Accepted Answer

A blanket restraint is most appropriate for a 3-year-old child who has a laceration of the forehead that needs stitches. This type of restraint can help keep the child still during the procedure, minimizing movement of the head and upper body.

Question 15

The nurse is developing a safety plan for an older adult client who has just been admitted to the nursing unit.The client has limited hearing and eyesight.His medications include furosemide (Lasix)and a baby aspirin.He still lives alone in his home and is able to do small household chores but his daughter comes over every week to take him grocery shopping.Which information will have an impact on the development of the safety plan? Select all that apply.

Accepted Answer

A) Furosemide (Lasix) can cause dehydration and electrolyte imbalances, increasing the risk of falls and confusion, which is important for safety planning.C) Limited hearing and eyesight increase the risk of accidents and injuries, necessitating modifications in the safety plan to address these sensory impairments.D) Living alone increases the risk of safety issues going unnoticed and the need for emergency response strategies in the safety plan.

Question 16

The nurse is caring for a client who recently began taking prescribed blood pressure medicine.Which teaching will be most important to this client in the prevention of falls?

Accepted Answer

Blood pressure medications can cause orthostatic hypotension, which is a sudden drop in blood pressure when standing up from a lying or sitting position. Sitting on the side of the bed for at least a minute before getting up allows the body time to adjust, reducing the risk of falls.

Question 17

The nurse is caring for a client who becomes occasionally confused.When the client has a period of confusion,he attempts to pull out his Foley catheter.When the client is oriented,he likes to do crossword puzzles.After receiving an order for restraints,which would be the best place(s)to place the restraint in this client?

Accepted Answer

The answer of The nurse is caring for a client...

Question 18

The nurse is assessing an older adult client who has come to the emergency department with a possible urinary tract infection.Which would alert the nurse that this client has been abused?

Accepted Answer

Bilateral contusions above the elbows could indicate that someone has grabbed the client forcefully, which is a sign of physical abuse. Bruises, especially in symmetrical patterns or in areas not typically injured through normal activities, can be indicative of abuse.

Question 19

The nurse is completing an assessment of an older adult client whose primary caretaker is the grandson.Which would alert the nurse that this client is a possible victim of emotional abuse?

Accepted Answer

Refusing to make eye contact can be a sign of fear or discomfort, which may indicate emotional abuse. The other options are more indicative of normal interactions or privacy concerns.

Question 20

The nurse is assisting a client to the bathroom when the client begins to have a tonic-clonic seizure.Which is the first thing that the nurse should do at this time?

Accepted Answer

The first action the nurse should take when a client begins to have a tonic-clonic seizure is to time the seizure. This is important for medical documentation and helps in assessing the severity and duration of the seizure, which are critical for determining the appropriate medical response and treatment.

Quiz 15: Safety