Ch 12

Question 1

The nurse is caring for a client who is on “fall precautions”. The nurse has placed a bed alarm under the client. Which term will the nurse correctly use in the documentation of client care?

1. A physical restraint
2. A chemical restraint
3. A safety monitoring device
4. A seizure monitoring device

Answer 1

3

Question 2

A nurse is offering client teaching related to fall prevention at a local senior center. Which learning points would be important to review as part of this teaching plan? Select all that apply

1. Wear shoes or well fitting slippers with nonskid soles
2. Have an uncluttered environment with securely fastened rugs
3. Ensure that proper lighting is available
4. Do not mix alcohol and medications, and avoid alcohol when necessary
5. Void on a frequent and scheduled basis

Answer 2

1, 2, 3, and 4

Question 3

A nurse is caring for a client who is acutely confused and agitated. The client has repeatedly attempted to get out of bed, and has also been trying to pull out all of his postoperative tubes and intravenous lines. The nurse intervenes by restraining the client with wrist restraints. Why are restraints indicated for this client?

1. To prevent the client from injuring self
2. To prevent the nurse from having extra work
3. To prevent the client from being embarrassed later
4. To prevent the PCP from having to order more medications

Answer 3

1

Question 4

The nurse is applying a belt restraint on a client. Which statement, if made by a nurse, indicates the need for further?

1. “Before applying the belt restraint, I need to make sure that the Velcro is intact.”
2. “If the client is going to a test on a stretcher, then I am able to remove the restraint.”
3. “If I am restraining the client in a chair, I will fastened the belt restraint at the back of the chair.”
4. “After I restrain the client, there should be a finger’s width between the belt and the client.”

Answer 4

2

Question 5

A home care nurse is meeting a client who has been discharged from the hospital with a new diagnosis of seizure disorder. Which action will the nurse implement?

1. Assure the client that stress at home will not be a precipitating factor for the seizures
2. Discuss the need to inform the Department of Motor Vehicles of the seizure disorder
3. Inform the client that she may drive to work, bathe, and cook at home as usual
4. Tell the client that the monitoring of her medications will be done by her PCP

Answer 5

2

Question 6

A client is beginning to exhibit seizure activity. UAP are in the room to provide assistance. Which safety measure may the nurse assign to the UAP?

1. Assess respiratory status and rate
2. Determine if the PCP needs to be called
3. Evaluate the type and length of seizure
4. Obtain blankets or other linens with which to pad the side rails

Answer 6

4

Question 7

The nurse has just applied hand mitts to a child with the goal of preventing self harm because the child was pulling at the intravenous lines and tubes. The nurse must assess and document which of the following related to the use of restraints? Select all that apply

1. Skin status beneath the restraints
2. Circulation in the restrained arm
3. IV site condition
4. Frequency of restraint assessment performed
5. Urine output

Answer 7

1, 2, 3, and 4

Question 8

The nurse accidently spills a water pitcher in the unit hallway. What is the priority action the nurse should take to prevent falls?

1. Go get towels or something to clean up the spill
2. Stay at the site of the spill and send someone else to call housekeeping to clean the spill
3. Call housekeeping from the nursing station to clean up the spill
4. Refill the water pitcher and take it to the client, then return to clean up the spill

Answer 8

2

Question 9

The nurse admitted an older client with a new diagnosis of syncope (dizziness) to the hospital. The client was previously healthy and vigorous. When performing a safety assessment of this client, the nurse determines which is the most significant factor in the clients risk for falls?

1. Hospital environment
2. Safe equipment
3. History of previous accidents and frequency of past accidents
4. Medical diagnosis

Answer 9

4

Question 10

The nurse is caring for a client who is confused and disoriented, has pulled out the urinary catheter twice and now has hematuria. The PCP orders restraints. What type of restraint would the nurse choose initially?

1. Mitt restraints
2. Limb restraints
3. Waist restraints
4. Vest restraints

Answer 10

1