NURS 3020 Study Guide for Exam 2 Fall 2023

NURS 3020 Study Guide for Exam 2 Fall 2023 The nurse knows that which assessment tool is not used to assess fall risk? A. Glasgow Falls Scale B. Johns Hopkins Hospital Fall Assessment Tool C. Morse Fall Scale D. Hendrich II Fall Risk Model - A The nurse is caring for a confused, combative patient. Which action would be considered last by the nurse to control behavior of the client? A. Orient the patient frequently. B. Apply restraints. C. Move the patient to a room close to the nurse's station. D. Encourage the family to spend time with the patient. - B The patient has a nursing diagnosis of Risk for Falls. The nurse identifies which goal to be most important? A. Patient will ambulate twice a day. B. Patient will have no symptoms of infection. C. Patient will perform activities of daily living. D. Patient will have no injuries during hospital stay. - D Which statement by the patient indicates to the nurse a teaching need regarding safety in the home? A. "I will put a night-light in every room." B. "I will not use an extension cord to plug in multiple items." C. "I will wash my throw rugs in the bathroom regularly." D. "I will keep all cleaning supplies out of reach of children." - C The nurse is teaching a student nurse about restraint use in patients. Which statement by the student nurse indicates a learning need regarding restraints? A. "Having all four side rails up on the bed is considered a restraint." B. "The use of restraints has been shown to decrease fall-related injuries." C. "Death has been associated with the use of restraints." D. "Medications administered to control behavior are considered a chemical restraint." - B The nurse is ambulating a patient back from the bathroom when the patient begins to have a seizure. Which action should the nurse do first? A. Lower the patient to the floor if standing. B. Mo