safety

Question 1

prenatal

Answer 1

• Risk from exposure to maternal smoking, alcohol consumption,
  addictive drugs, x-rays, certain pesticides

Question 2

newborn/infant

Answer 2

• Susceptible to burns, falls, choking, Need immunizations
• Car seats (children under 2 rear facing, children up to 12 in approved seats, under 12 in back seat)

Question 3

toddler & preschooler

Answer 3

• Injuries leading cause of death in children over age 1
• Risk from poisoning, falls, fire, traffic, strangers (human & animal)

Question 4

school age child

Answer 4

• Risk of sports injuries —Helmets, learn to swim
• Risk from stranger, firearms, traffic

Question 5

adolescent

Answer 5

• Risk due to peer pressure/ risk taking personality
• Risks due to substance abuse, unsafe sex, driving accidents, firearms

Question 6

older adult

Answer 6

• Slowed reflexes—can affect driving
• Risk for falls, burns
• Sensory perceptual alterations—vision, hearing, touch sense

Question 7

environmental factors that affect safety

Answer 7

• Ventilation– CO poisoning
• Home hazards—throw rugs, guns, chemical storage, electrical
• Poor food handling
• Poor hygiene—especially hand washing
• Crowded living conditions
• Poor Insect & rodent control, sewage disposal
• Heat or cold exposure
• Unfamiliar environment, equip

Question 8

psychological factors that affect safety

Answer 8

• Depression, Anxiety can impair judgment

Question 9

physiological factors that affect safety

Answer 9

• Musculoskeletal impairment—arthritis, paralysis, fractures
• Cognitive impairment
  o Fatigue
  o Altered level of consciousness—injury, medication,
  anesthesia
  o Disease states—psychosis, dementia
  o Impaired judgment due to disease, medications, alcohol, drugs
• Cardiovascular and respiratory systems
  o Diminished tolerance for activity with age, disease
  o Orthostatic hypotension
• Sensory or communication impairment
  o Effects of medication, disease
  o Neuropathy
  o Sensory overload or deprivation
  o Changes in vision/hearing with age

Question 10

characteristics of safety

Answer 10

■ Truly risk free environment rare
■ Pervasiveness
– Consciously, people assume or neglect responsibility for safety
■ Perception
– Safety practices are learned
■ Management
– Prevention is a major characteristic

Question 11

falls

Answer 11

– Risk higher in older adults
– Causes
■ Sleep deprivation
■ New environment
■ Change in medication
■ Decreases physical strength
due to illness

Question 12

client inherent accidents

Answer 12

– Seizures: if side rails aren’t up they could fall on the floor
– Self-inflicted harm: in psych

Question 13

procedure related accidents

Answer 13

– Medication & fluid administration errors
– Improper performance of procedures
– Improper identification of patients

Question 14

ineffective communication among caregivers

Answer 14

– Telephone & verbal orders
– Lack of standardized abbreviations

Question 15

equipment related accidents

Answer 15

• O2: flammable
• electrical hazards
• malfunctioning of clinical alarms

Question 16

assessment of safety: nursing history

Answer 16

■ Current safety practices (seatbelt practices, immunizations,etc)
■ Risk identification
– Risks in workplace (what kind of job? eyewear? ear protection)
– Risk in home (look at home setup and where are they placed)
– Risk in HC agency
■ Fall risk assessment
■ Medications taken
■ Previous history of falls
- if they end up on the ground w/o meaning, that is a fall

Question 17

nursing history

Answer 17

■ Difficulties/ recent changes
– Vision, hearing, taste
– Smell, sensation, communication
- can they smell smoke? can they taste rotten or spoiled food?
■ USE of assistive devices (hearing aids, glasses)
■ Problems with communication
– Language, sensory deficits, cognitive deficits
- someone might say help but it’s the only english word they know

Question 18

physical exam LOC

Answer 18

– Alert (awake)
– Lethargic (Somnolent)
■ Extreme drowsiness (could answer questions but go right back to sleep)
– Stupor (Semicomatose) (elicit pain response = whole body will react)
■ Responds unpurposefully to painful stimuli
– Coma (no consciousness)

Question 19

physical exam – orientation and glasgow

Answer 19

■ Orientation
– Person, time, place, situation
- do they know who they are? month or season? do they know they’re in the hospital and why?
■ Glasgow Coma Scale
– Normal 15
– Patient in coma scores 7 or less

Question 20

physical exam – visual and hearing acuity and touch sense

Answer 20

■ Visual & hearing ability
– Availability/ Use of Assistive Devices
■ Touch Sense
– Particularly important in extremities

Question 21

sensory processing ability

Answer 21

• ability to deal w/ stimuli that’s coming in and process it

Question 22

sensory deprivation

Answer 22

– Decrease or lack of meaningful stimuli
– Perceive remaining stimuli in distorted manner (someone climbing out of bed bc they hear a baby crying)
– Symptoms
■ Yawning, drowsiness
■ Reduced attention span
■ Impaired problem solving
■ Hallucinations, confusion
– Causes
■ Non-stimulating environment
■ Inability to receive stimuli

Question 23

sensory overload

Answer 23

– Inability to process or manage amount of stimuli
– Symptoms
■ C/O fatigue, sleepiness
■ Irritability, anxiety, restlessness
■ Disorientation
■ Reduced problem solving ability
■ Increased muscle tension
– Causes
■ Quantity of internal stimuli
■ increase external stimuli
■ Inability to disregard stimuli
■ Sleep deprivation

Question 24

physical exam – ability to communicate effectively

Answer 24

– Aphasia
- stroke pts
– Language barrier
– Inability to read

Question 25

cardiovascular and respiratory assessment for safety

Answer 25

– Heart & lung sounds
– Activity tolerance
– Orthostatic hypotension (may become dizzy and fall)

Question 26

mobility assessment on safety

Answer 26

– ROM, muscle strength
– Coordination
– Ability to perform ADL
– Assistive devices needed
– Get up & go test

Question 27

presence of invasive lines assessment of safety

Answer 27

– Indwelling (foley) Catheter
– Intravenous lines
– Nasogastric tubes
- can trip on it and rip it out
- infxn risks but also safety

Question 28

Assessment of Safety: Measurement

Answer 28

• hgb: low hgb can cause act intolernance bc you’re getting low amt of O2 to your tissues

Question 29

risk diagnosis for safety

Answer 29

■ Risk for injury
– Vulnerable for injury as a result of environmental conditions interacting with the individual’s adaptive and defensive resources which may compromise health
– Risk for Fall
– Risk for Aspiration
– Risk for Poisoning
– Risk for Suffocation
– Risk for Thermal injury (Burns)

Question 30

impaired verbal communication

Answer 30

– Decreased ability to express thoughts, feelings, messages, or information through speech
- good for someone who can’t receive process or transmit in effect way to get their needs met

Question 31

interventions

Answer 31

■ Help clients develop personal safety habits
– Patient & family teaching for community safety
– In health care environment
■ Orient to setting
■ Call lights (need to be w/in reach)

Question 32

maintain existing fxn

Answer 32

– Provide sufficient stimuli (can use a whiteboard. keeps pt oriented. date, name, phone #, room #)
– Ensure use of assistive devices
– Use touch appropriately
– Maximize residual function (good oral hygiene)

Question 33

promote communication with patients

Answer 33

– Use simple/ short questions
– Use yes/ no questions
– Get medical interpreter as necessary –> to explain med procedures. hospital employee is okay if they speak the language
– Communication board

Question 33

promote orientation

Answer 33

– Address client by name (don’t say sweetie or honey)
– Provide clock, radio, calendar
– Adjust environment
– Appropriate social interaction (some ppl might be calmer w/ visitors)
– Minimize unnecessary stimuli (turn off unnecessary alarms, bright lights, etc)

Question 34

fall prevention in HC environment

Answer 34

– Keep room free of clutter
– Appropriate footwear (gripper socks or shoes)
– Side-rails, grab bars, locks on w/c
- only put all 4 side-rails if pt asks for it
– Bed alarms: goes off when they get up

Question 35

minimize use of restraints

Answer 35

– Restraint is a protective device, material or equipment attached to or adjacent to body that restricts freedom of movement or normal access to one’s body
– Omnibus Budget Reconciliation Act of 1987 (OBRA)
■ All less restrictive interventions have been tried first
■ Other disciplines consulted—MD order
■ Supporting documentation of use provided
– Provide ongoing assessment/ evaluation of patient in restraints

Question 36

cultural considerations

Answer 36

■ Clients from diverse backgrounds
– Significant threat if come from a culture of violence
– Survivors of war, PTSD
■ Low health literacy
■ Enlist family presence and support

Question 37

prevent injury during seizures

Answer 37

– Pad siderails? – can’t get to call light if these are on
– During seizure remain with patient and call for help as necessary

Question 38

10 rights of medication administration

Answer 38

■ Right drug to right patient
■ At right time by right route
■ In the right dosage
■ With the right documentation, right assessment, right
evaluation and right education
■ With the right to refuse the medication

Question 39

medication/treatment safety

Answer 39

– Check all alarms to be sure they are correctly set
– Check procedure manual as necessary
– Remove malfunctioning equipment
- no trailing zeros but put zeros before the decimal

Question 40

fire/electrical safety

Answer 40

– Know fire plan
■ Where are fire extinguishers on unit
– RACE
■ Rescue client, Activate alarm, Confine fire, Extinguish fire
– Use O2 properly

Question 41

radiation safety, heat/cold safety, and effective communication

Answer 41

■ Radiation safety
– Shielding
– Distance
- don’t stay in room for x-rays
■ Heat/ cold safety (wrap in towel)
■ Effective communication
– “Read back” all verbal orders
– Use only approved abbreviations

Question 42

nic

Answer 42

■ Falls
– Fall prevention
■ Risk for injury
– Environment management
– Emotional support

Question 43

Which of the following parents need additional instruction regarding safety?

Answer 43

A. Parent A states “Now that my child is 2 years old I can let her sit in the front seat of the car with me.” (CORRECT)
B. Parent B states “I make sure Tommy wears a helmet when he rides his bicycle.”
C. Parent C states “ I have spoken to my teenager about safe sex practices.”
D. Parent D states “My 8 year old is taking swimming lessons at the YMCA.”

Question 44

Which of the following would provide meaningful stimuli for a client? Select all that apply.

Answer 44

A. A clock or calendar with large numbers (CORRECT)
B. A radio that is kept on all day at low volume
C. Family pictures and possessions (CORRECT)
D. Interaction with nurse or other patients (CORRECT)

Question 45

Interventions for the client with actual or potential sensory alterations include all of the following except

Answer 45

A. Promoting optimal function of existing senses
B. Preventing additional sensory loss
C. Promoting client’s acceptance of dependency (CORRECT)
D. Controlling the environment to create meaningful sensory stimuli

Question 46

A patient has been newly admitted to a medicine unit with a history of diabetes and advanced heart failure. The nurse is assessing the patient’s fall risks. Which of the following is the proper order
of steps for the “Timed Get-up and Go Test” (TGUGT)?
1. Have patient rise from straight-back chair without using arms for support.
2. Begin timing.
3. Tell patient to walk 10 feet as quickly and safely as possible to a line you marked on the floor, turn around, walk back, and sit down.
4. Check time elapsed.
5. Look for unsteadiness in patient’s gait.
6. Have patient return to chair and sit down without using arms for support.

Answer 46

2, 1, 3, 5, 6, 4

Question 46

The nursing assessment of an 80-year-old patient who demonstrates some confusion but no anxiety reveals that the patient is a fall risk because she continues to get out of bed without help despite frequent reminders. The initial nursing intervention to prevent falls for this patient is to:

Answer 46

A. Place a bed alarm device on the bed. (MOST COST EFFECTIVE. CORRECT)
B. Place the patient in a belt restraint. (last resort)
C. Provide one-on-one observation of the patient.
D. Apply wrist restraints. (last resort)

Question 47

A patient has been on contact isolation for 4 days because of an infection. They have had few visitors and few opportunities to leave their room. Their ambulation is also still limited. Which are the correct nursing interventions to reduce sensory deprivation? (Select all that apply.)

Answer 47

A. Teaching how activities such as reading and using crossword puzzles provide stimulation (CORRECT)
B. Moving them to a room away from the nurse’s station
C. Turning on the lights and opening the room blinds (CORRECT)
D. Sitting down, speaking, touching, and listening to their feelings and perceptions (CORRECT)
E. Providing auditory stimulation for the patient by keeping the TV on continuously