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A nurse is assisting with conducting a home hazard assessment for a client who has dementia.
Which of the following findings indicates an understanding of home safety?
a) an extension cord is secured under a rug
b) the edges of stairs are marked with brightly colored tape
c) a toaster is plugged in when not in use
d) the water heater is set to 55 degrees C - Answer b) the edges of stairs are marked with
brightly colored tape
A nurse is preparing to conduct a fall risk screening on a client. Which of the following variables
will the nurse use to evaluate the client? Select all that apply
a) fall history
b) medical diagnosis
c) use of assistive devices
d) mental status
e) do-not-resuscitate status - Answer a) fall history
b) medical diagnosis
c) use of assistive devices
d) mental status
A nurse is assisting with teaching about warning signs from a co-worker that might indicate
future workplace violence. Which of the following behaviors should the nurse include?
a) legitimate absenteeism
b) strict adherence to facility policies
c) consistent adequate work performance
d) frequent reports of not being treated fairly - Answer d) frequent reports of not being
treated fairly
, a) tie the restraints to the siderails on the client's bed
b) remove the restraints with each vital sign check
c) use the square knot to secure the restraints
d) make sure one finger can fit under the restraints - Answer b) remove the restraints with
each vital sign check
A nurse discovers a small fire in a client's room. After removing the client to safety, which of the
following actions should the nurse take next?
a) extinguish the fire
b) close the windows in the client's room
c) close the client's door
d) activate the fire alarm - Answer d) activate the fire alarm
A nurse is caring for a client who is at risk for suicide. Which of the following actions should the
nurse take? Select all that apply
a) place the client on round-the-clock surveillance
b) remove the objects from the room that the client could use to arm themselves
c) search items brought into the client's room by visitors
d) refrain from asking the client if they intend to harm themselves
e) screen the client for suicide ideation - Answer a) place the client on round-the-clock
surveillance
b) remove the objects from the room that the client could use to arm themselves
c) search items brought into the client's room by visitors
e) screen the client for suicide ideation
A nurse is planning to use the identify, situation, background, assessment, recommendation,
read-back (ISBARR) tool to communicate with a provider about a client. Which of the following
information is included in the assessment component of ISBARR?
a) the client's admitting diagnosis
b) the client's medical history