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A 75-year-old client, hospitalized with a cerebrovascular accident (stroke), becomes disoriented at times and tries to get out of bed, but is unable to ambulate without help. What is the most appropriate safety measure?
1) Restrain the client in bed.
2) Ask a family member to stay with the client.
3) Check the client every 15 minutes.
4) Use a bed exit safety monitoring device.
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People who are old or disabled have problem in protecting themselves, so a nurse should take-charge in these cases to assess what kind of patients require more help than others. The most important duty of a nurse is to save the client's life. In emergencies a nurses' first priority action should be to save the patient's life. Nurses should always be aware as to what constitutes a safe surrounding.
In the given case, restraining the patient back to bed might irritate the patient, and in case of emergency getting out of bed might be important. Asking a family member will not be helpful, as the family member will not be able to make the patient get out of it. Checking the client after every 15 minutes is not feasible, as the nurse has other works also.
Hence, the options 1, 2 and 3 are incorrect.
Using a bed exit monitoring device is the best intervention as this allows to alert the nurse. It also allows some sense of independence to the patient. It will also give the nurse some sort of assurance that in case of emergency she will able to report immediately.
Hence, the correct answer is option
.
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A nurse sees smoke emerging from the suction equipment being used. Which is the greatest priority in the event of a fire?
1) Report the fire.
2) Extinguish the fire.
3) Protect the clients.
4) Contain the fire.
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The most important duty of a nurse is to save the client's life. In emergencies a nurses' first priority action should be to save the patient's life. Motor vehicles, fire, and burns are the major causes of injuries. Nurses should always be aware as to what constitutes a safe surrounding.
People who are old and disabled have the problem in protecting themselves, so a nurse should take-charge in these cases to assess what kind of patients require more help than others. In case of a fire the most important nursing action is not reporting the fire. Extinguishing the fire will take time, and cause loss of life. Containing the fire is not the job of a nurse, and will lead to more casualties.
Hence, the options 1, 2 and 4 are incorrect.
Protecting the life of a client or patient is the utmost responsibility of the nurse. A nurses' main duty is to serve a patient, and she has to put it before everything, even her own life. Patient's life is the most important.
Hence, the correct answer is option
.
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A mother and her 3-year-old live in a home built in 1932. Which NANDA nursing diagnosis is most applicable for this child?
1) Risk for Suffocation
2) Risk for Injury
3) Risk for Poisoning
4) Risk for Disuse Syndrome
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The nurses have a great role in the patient's life as they are responsible for providing the best care during hospitalization. They also protect them from various emergencies as well. The most important duty of a nurse is to save the client's life. In emergencies a nurses' first priority action should be to save the patient's life.
Nurses should always be aware as to what constitutes a safe surrounding. In the given case, the risk of suffocation is not applicable. The risk of suffocation will apply only if the house is too small or they live in an isolated room. Risk of injury, and disuse syndrome is not relevant here.
Hence, the options 1, 2 and 4 are incorrect.
The correct diagnosis will be of risk for poisoning. As the house is too old and there is a risk of leakage of some harmful agents or substances. These agents can cause poisoning and can lead to the death.
Hence, the correct answer is option
.
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Which nursing intervention is the highest in priority for a client at risk for falls in a hospital setting?
1) Keep all of the side rails up.
2) Review prescribed medications.
3) Complete the "get up and go" test.
4) Place the bed in the lowest position.
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Moore is a 72-year-old widower who is recovering from a fall in which he fractured his hip and underwent surgical repair 1 week ago. He will be staying with his son for 2 weeks after he is discharged from the hospital, but he is eager to return to his own home. Once he is home, his son will visit nightly after work, he will receive Meals- on-Wheels once a day, and a home health care attendant will visit weekly to assist him with hygienic care until he is more independent. Mr. Moore's wife died 3 years ago, but he has remained independent and continued his social functions. He lives in a small single-level house with hts dog and cat, and he enjoys gardening. Prior to fracturing his hip he walked his dog daily. You will be his home health care nurse.
What are some of the more obvious factors that may affect Mr. Moore's safety as he returns home?
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Moore is a 72-year-old widower who is recovering from a fall in which he fractured his hip and underwent surgical repair 1 week ago. He will be staying with his son for 2 weeks after he is discharged from the hospital, but he is eager to return to his own home. Once he is home, his son will visit nightly after work, he will receive Meals- on-Wheels once a day, and a home health care attendant will visit weekly to assist him with hygienic care until he is more independent. Mr. Moore's wife died 3 years ago, but he has remained independent and continued his social functions. He lives in a small single-level house with hts dog and cat, and he enjoys gardening. Prior to fracturing his hip he walked his dog daily. You will be his home health care nurse.
What strengths do you note about Mr. Moore that may protect him from injury when he returns home?
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A nurse who is teaching a group of adults ages 20 to 40 years old about safety is going to ensure that which topic is a priority?
1) Automobile crashes
2) Drowning and firearms
3) Falls
4) Suicide and homicide
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The nurse, at change-of-shift report, learns that one of the clients in his care has bilateral soft wrist restraints. The client is confused, is trying to get out of bed, and had pulled out the IV line, which was subsequently reinserted. Which action(s) by the nurse is appropriate? Select all that apply.
1) Document the behavior(s) that require continued use of the restraints.
2) Ensure that the restraints are tied to the side rails.
3) Provide range-of-motion exercises when the restraints are removed.
4) Orient the client.
Assess the tightness of the restraints.
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Moore is a 72-year-old widower who is recovering from a fall in which he fractured his hip and underwent surgical repair 1 week ago. He will be staying with his son for 2 weeks after he is discharged from the hospital, but he is eager to return to his own home. Once he is home, his son will visit nightly after work, he will receive Meals- on-Wheels once a day, and a home health care attendant will visit weekly to assist him with hygienic care until he is more independent. Mr. Moore's wife died 3 years ago, but he has remained independent and continued his social functions. He lives in a small single-level house with hts dog and cat, and he enjoys gardening. Prior to fracturing his hip he walked his dog daily. You will be his home health care nurse.
While hospitalized, Mr. Moore experienced some mild confusion during the night, but his nurses decided not to restrain him. What are the best reasons for avoiding the use of restraints for clients such as Mr. Moore?
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Moore is a 72-year-old widower who is recovering from a fall in which he fractured his hip and underwent surgical repair 1 week ago. He will be staying with his son for 2 weeks after he is discharged from the hospital, but he is eager to return to his own home. Once he is home, his son will visit nightly after work, he will receive Meals- on-Wheels once a day, and a home health care attendant will visit weekly to assist him with hygienic care until he is more independent. Mr. Moore's wife died 3 years ago, but he has remained independent and continued his social functions. He lives in a small single-level house with hts dog and cat, and he enjoys gardening. Prior to fracturing his hip he walked his dog daily. You will be his home health care nurse.
What do you need to assess with regard to Mr. Moore's safety and what suggestions can you make for enhancing his safety?
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An 87-year-old man is admitted to the hospital for cellulitis of the left arm. He ambulates with a walker and takes a diuretic medication to control symptoms of fluid retention. Which intervention is most important to protect him from injury?
1) Leave the bathroom light on.
2) Withhold the client's diuretic medication.
3) Provide a bedside commode.
4) Keep the side rails up.
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A client is being admitted to the hospital because of a seizure that occurred at his home. The client has no previous history of seizures. In planning the client's nursing care, which of the following measures is most essential at this time of admission? Select all that apply.
Place a padded tongue depressor at the head of the bed.
1) Pad the bed with blankets.
2) Inform the client about the importance of wearing a medical identification tag.
3) Teach the client about epilepsy.
4) Test oral suction equipment.
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When planning to teach health care topics to a group of male adolescents, which topic should the nurse consider a priority?
1) Sports contribute to an adolescent's self-esteem.
2) Sunbathing and tanning beds can be dangerous.
3) Guns are the most frequently used weapon for adolescent suicide.
4) A driver's education course is mandatory for safety.
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Medication errors can place the client at significant risk. Which practice(s) will help decrease the possibility of errors? Select all that apply.
1) Hire only competent nurses.
2) Improve the nurse's ability to multitask.
3) Establish a reporting system for "near misses."
4) Communicate effectively.
5) Create a culture of trust.
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