NCHP Exam 2 Practice Questions fully solved & updated

Which cues would the nurse use to determine a patient's safety needs? Select all that apply. Subjective data related to the patient's symptoms Patient's family history Subjective information about the patient's chief complaint Patient's history of exposures to environmental hazards Objective assessment focused on the affected body systems - answer-Subjective data related to the patient's symptoms Subjective information about the patient's chief complaint Patient's history of exposures to environmental hazards Objective assessment focused on the affected body systems To specifically assess the patient's safety risks related to health issues, which question would the nurse ask? What safety concerns do you have? Have you ever had a seizure? Who else lives with you? Do you require assistance with bathing? - answer-Have you ever had a seizure? Which question would the nurse ask to assess a patient's understanding of the risks of chemicals? Where do you store your household cleaners? Do you know why you take your current set of medications? Are separate cutting surfaces used for cutting raw fish and meats? Do you have any safety concerns at home or work? - answer-Where do you store your household cleaners? Educating patients about electrical cord safety is important in preventing which specific home safety hazard? Fire Outdoor safety hazards Carbon monoxide poisoning Biohazards - answer-Fire To assess the patient's risk for exposure to biohazards in the home, which question would the nurse ask? Do you have air conditioning? What recreational activities do you engage in? Is there adequate outside lighting? Do you or does anyone in the home use hypodermic needles? - answer-Do you or does anyone in the home use hypodermic needles? Which member of the interprofessional team would the nurse consult to evaluate a patient for safe performance of activities of daily living (ADLs)? Social worker Physical therapist Occupational therapist Unlicensed assistive personnel - answer-Occupational therapist Which member of the interprofessional team would the nurse consult to evaluate a patient who is a fall risk? Health care provider Physical therapist Occupational therapist Unlicensed assistive personnel - answer-Physical therapist During an assessment, the nurse learns that a patient and child are living in a car. Which member of the interprofessional team would the nurse consult with to evaluate these individuals? Health care provider Social worker Physical therapist Occupational therapist - answer-Social worker A fire prevention plan must include changing batteries in smoke alarms (detectors) at least every _______ months. - answer-6 Many hospitals use the acronym RACE to describe emergency fire response. Which terms stand for the letters in RACE? Rescue, Advise, Comfort, Expedite Rescue, Alarm, Contain, Extinguish Restrain, Action, Continue, Emergency Resuscitate, Action, Control, Emergency - answer-Rescue, Alarm, Contain, Extinguish Which action would the nurse take first when discovering a fire in a patient's room? Extinguish the fire. Contain the fire. Remove the patient from the room. Sound the alarm. - answer-Remove the patient from the room. The nurse is caring for a 72-year-old patient who is on bed rest after hip surgery for an injury sustained from a fall at home. The patient has a history of diabetes and ongoing dementia. Upon assessment, the nurse notes an intravenous (IV) infusion, a nasogastric tube, and a urinary drainage catheter. According to the Morse Fall Scale, what is the patient's total score? - answer-75 The patient is a high risk for falls: History of falling—25; Secondary diagnosis—15; Ambulatory aid—0; IV/heparin lock—20; Gait/transferring—0; Mental status—15 = 75 points. The nurse is asking the patient a series of questions about the patient's activities of daily living. The patient asks the nurse why that information is important. Which nursing response is appropriate? "The answers to these questions will help us determine if you need any assistance at home." "This information will help your health care provider determine if you need to be placed in a skilled nursing facility." "The questions are designed to get you to think about going home from the hospital." "This is part of our regular patient assessment form that we must complete." - answer-"The answers to these questions will help us determine if you need any assistance at home." A patient is on a large number of medications, and the nurse is concerned about the patient's personal ability to manage taking all the medications at home. Which questions would the nurse ask to assess the patient's potential safety risk? Select all that apply. "Do you take your medications consistently?" "Do any young children live in the home who know about your medications?" "Do you know how to take these prescriptions?" "Do you know when to take your drugs?" "Do you know why the health care provider has prescribed these medications?" - answer-"Do you take your medications consistently?" "Do you know how to take these prescriptions?" "Do you know when to take your drugs?" "Do you know why the health care provider has prescribed these medications?" A patient with paraplegia is being prepared for discharge from a spinal cord rehabilitation unit. Which question is most important for the nurse to ask when performing a home safety assessment? "Do you have a carbon monoxide detector?" "Do you have a plan to exit the home in case of an emergency?" "Where are your medications stored?" "Do you have a fire extinguisher?" - answer-"Do you have a plan to exit the home in case of an emergency?" Which factor is a patient-related fall risk hazard? Wound drain Floor surfaces Intravenous access Incontinence - answer-Incontinence The nurse is planning care for a patient who is 70 years old, lives at home with her healthy 50-year-old daughter, and swims and walks daily. When the patient says she wants to learn more about staying safe at home, which need would the nurse identify as the priority? Fall prevention Drowning precautions Preventing methicillin-resistant Staphylococcus aureus (MRSA) Avoidance of hypothermia - answer-Fall prevention A 90-year-old patient taking multiple medications is being discharged to home. Which members of the interprofessional team would the nurse consult with to evaluate fall risk? Select all that apply. Pharmacist Social worker Physical therapist Unlicensed assistive personnel Occupational therapist - answer-Pharmacist Physical therapist Occupational therapist The nurse identifies that a patient has difficulty putting on shoes and buttoning a shirt after the examination. Which goal would the nurse create as part of the plan of care? Patient will select appropriate clothing to wear. Patient will put on shoes and button shirt. Patient will perform own activities of daily living (ADLs). Patient will dress self within 1 month. - answer-Patient will dress self within 1 month. The nurse is educating a patient about home safety. Which patient response indicates that further nursing teaching is required? "My electrical outlets have covers on them." "I shave with my electric razor when I am in the tub for convenience." "There is a fire extinguisher in the kitchen." "I have smoke detectors in each room." - answer-"I shave with my electric razor when I am in the tub for convenience." The nurse is admitting a patient who is a fall risk. Which room will the nurse assign? Room at the end of the hallway Room nearest the nurses' station Double room with a roommate Room in the middle of the hallway - answer-Room nearest the nurses' station The nurse is evaluating a patient's understanding of home safety measures. Which patient response indicates that teaching has been effective? "I checked my floorboards to make sure they are even." "I only need to use my cane when I leave the house." "I don't like night-lights because they keep me awake." "I throw my used diabetic needles into a soda can when I am done with them." - answer-"I checked my floorboards to make sure they are even." Which national organization categorizes injuries as intentional or unintentional? The Joint Commission (TJC) Quality and Safety Education for Nurses (QSEN) Agency for Healthcare Research and Quality (AHRQ) National Center for Health Statistics (NCHS) - answer-National Center for Health Statistics (NCHS) Which teaching points will the nurse include when teaching a community group about injuries? Select all that apply. Unintentional injuries are unplanned incidents. Unintentional injuries typically result from deliberate acts of violence. Unintentional injuries do not account for many deaths within the United States. The risk factors for intentional injuries are better understood than those of unintentional injuries. Intentional injuries include events such as falls, drownings, and fire-associated injuries. - answer-Unintentional injuries are unplanned incidents. The risk factors for intentional injuries are better understood than those of unintentional injuries. Which organization places a focus on patient safety when evaluating health care agencies for accreditation? The Joint Commission World Health Organization Centers for Disease Control and Prevention National Institutes of Health - answer-The Joint Commission The Joint Commission reevaluates National Patient Safety Goals every _____ months. - answer-12 When teaching a community group about individual safety, which factors would the nurse include? Select all that apply. Workplace Physical age Developmental level Neighborhood environment Participation in school activities - answer-Physical age Developmental level Which factor is most likely the result of an impaired renal system? Alteration of senses Orthostatic hypotension Impaired excretion of medications Disruption of the body's protective barrier - answer-Impaired excretion of medications Which safety risks would the nurse include when teaching the parents of an 18-month-old about safety precautions? Select all that apply. Choking on grapes Drowning in swimming pools Strangulation from blind cords Dehydration from sitting in a hot car Accidental ingestion of medication Head or neck injury related to trampoline use - answer-Choking on grapes Drowning in swimming pools Strangulation from blind cords Dehydration from sitting in a hot car Accidental ingestion of medication The nurse recognizes that poisoning symptoms can resemble symptoms of which other disorders? Select all that apply. Brain attack Seizure Alcohol intoxication Hypoglycemia Delirium Strep throat - answer-Brain attack Seizure Alcohol intoxication Hypoglycemia Delirium Which teaching would the nurse provide to a patient who asks how to best prepare fruits and vegetables to eat? Disinfect with an organic household cleaner. Rinse under running water. Use a small amount of dish detergent. Wash in solution made with 1 gallon of water and 1 teaspoon of bleach. - answer-Rinse under running water. Which types of footwear would the nurse recommend to a patient who plans to use a riding lawn mower regularly this summer? Select all that apply. Sneakers Velcro, nonslip shoes Shoes with sturdy laces Sandals, as the feet are away from blades Rubber boots - answer-Velcro, nonslip shoes Shoes with sturdy laces The nurse is talking with a new graduate nurse about medication administration errors. Which statement from the new graduate nurse shows a need for further education? "Confusion between sound-alike or similarly spelled drug names causes many medication errors." "Many medication errors occur during transfers from nurse to nurse across units and across settings." "Because drugs are delivered through an automated dispensing system, the risk for medication errors is low." "Nurses may miscalculate the number of tablets for a medication dose because of a patient's intravenous (IV) pump alarm beeping." - answer-"Because drugs are delivered through an automated dispensing system, the risk for medication errors is low." Which negative outcomes resulting from the use of physical restraints would the nurse identify? Select all that apply. Death Diarrhea Fractures Incontinence Reduced bone mass - answer-Death Fractures Incontinence Reduced bone mass A nurse in which situations needs to immediately enact precautions to minimize self-exposure to radiation? Select all that apply. Assisting a patient with agitation during a radiographic procedure Working in a special procedure area where radiation is delivered Caring for a patient receiving radioactive iodine treatment Talking with a patient who is receiving a dual-energy x-ray absorptiometry (DEXA) scan Helping a patient who had radiation therapy last week eat - answer-Assisting a patient with agitation during a radiographic procedure Working in a special procedure area where radiation is delivered Caring for a patient receiving radioactive iodine treatment Which Quality and Safety Education for Nurses competency does the nurse observe when questioning the approach to routine care? Patient-centered care Quality improvement Evidence-based practice Informatics - answer-Evidence-based practice Which nursing attitude is needed to increase patient safety? Supports care for patients that differs from care desired for self Recognizes the patient's personal beliefs Values own role in preventing errors Appreciates the nurse's role in providing pain relief - answer-Values own role in preventing errors Nurses are professionally accountable for ______ Quality and Safety Education for Nurses competencies. - answer-6 Which statement describes the main goal of the Quality and Safety Education for Nurses (QSEN) project? Prepare future nurses to advance quality and safety. Allocate resources for safety program implementation. Minimize the risk for harm to older adult patients by injury. Assist nurses to educate patients about safety concerns. - answer-Prepare future nurses to advance quality and safety. Which individuals are more likely to be involved in an intentional injury? Select all that apply. A young female with a history of falling An adolescent female with severe depression A young adult male with a history of violence An older adult male diagnosed with dementia A middle-aged female who was abused as a child - answer-An adolescent female with severe depression A young adult male with a history of violence A middle-aged female who was abused as a child Which guidelines regarding the use of abbreviations in documentation would the nurse follow? Select all that apply. Use MS for MSO4 and MgSO4. Use of QD, QOD, and qd are discouraged. Documentation of "5 mg" is acceptable. Using "unit" as a form of measurement is appropriate. For doses under 1, use a leading zero (e.g., 0.5 mg). - answer-Documentation of "5 mg" is acceptable. Using "unit" as a form of measurement is appropriate. For doses under 1, use a leading zero (e.g., 0.5 mg). Which external/environmental factors would the nurse identify as affecting an individual's safety? Select all that apply. Residing in a high-crime area Living with an abusive, alcoholic individual Developmentally performing below one's age level Being diagnosed with a disease at a very young age Being an older adult over the age of 65 - answer-Residing in a high-crime area Living with an abusive, alcoholic individual A 50-year-old construction worker arrives at the hospital reporting stomach cramps and vomiting for several days. He smokes a pack of cigarettes daily and lives near a landfill. Which external/environmental factor would the nurse identify that likely has affected the patient's safety? Age Developmental level Lifestyle behaviors Place of residence - answer-Place of residence Which question would the nurse ask a teenager related to a unique risk factor for this age group? "Do you text while driving?" "Do you know how to swim?" "Do you work in a dangerous environment?" "Does your home contain furniture with sharp corners?" - answer-"Do you text while driving?" When teaching a group of new parents about feeding their children, which food safety information would the nurse provide? Select all that apply. Monitor food expiration dates closely. Cook food to the appropriate temperature. Store leftover food in its original can. Avoid raw meat that is light red in color. Always cook pork for a longer amount of time than beef. - answer-Monitor food expiration dates closely. Cook food to the appropriate temperature. The nurse has taught a neighborhood group about home safety. Which patient statement demonstrates a need for further teaching? "Proper safety gear should be used when operating power tools." "Weather should be taken into consideration when riding a bicycle." "Risk for injuries can be minimized through education programs for skating and bicycling." "I will store my gun and ammunition together in a locked case." - answer-"I will store my gun and ammunition together in a locked case." The nurse is preparing to discuss medication administration with a family. Which teachings would the nurse provide? Select all that apply. Never take larger or more frequent doses of medications. Do not refer to medication as "candy" when speaking to children. Read over directions in direct light, and follow all directions on medication labels. Dispose of used needles in the trash to avoid needlestick injuries. Contact the health care provider if you have any questions about dosing. - answer-Never take larger or more frequent doses of medications. Do not refer to medication as "candy" when speaking to children. Read over directions in direct light, and follow all directions on medication labels. Contact the health care provider if you have any questions about dosing. Which group would the nurse identify as having the highest risk for drowning? Children between 1 and 4 years of age Children between 5 and 10 years of age Adults who do not use approved life jackets Teenagers who are under the influence of alcohol - answer-Children between 1 and 4 years of age Which environmental risk would the nurse identify as often leading to falls? Pollution Inadequate lighting Poor lifting techniques Communicable diseases - answer-Inadequate lighting A patient who is intubated and confused continues to try to pull out the endotracheal tube. When all other measures to divert the patient's attention fail, the nurse applies soft wrist restraints, under the health care provider's order, to protect the patient's airway. Which assessment finding alerts the nurse to reapply the restraint? Fingertips warm to the touch Capillary refill at 2 seconds in both hands Reduced attempts at pulling the endotracheal tube Impeded pulse on wrists - answer-Impeded pulse on wrists Which teachings would the nurse provide when teaching a group of assistive personnel about methicillin-resistant Staphylococcus aureus (MRSA) and infection control? Select all that apply. It may lead to sepsis. It is resistant to common antibiotics. It is associated with infections of the skin. It generally affects the patients in the hospital who are the weakest or sickest. It commonly enters the body through invasive procedures. - answer-It may lead to sepsis. It is resistant to common antibiotics. It is associated with infections of the skin. Which items would the nurse identify as an example of a physical restraint? Select all that apply. Ankle bracelet Wrist cuffs Safety jacket Four raised side rails Medication - answer-Wrist cuffs Safety jacket Four raised side rails Which "rights" are considered to be the "Original 5" rights of medication administration? The right drug, dose, time, patient, label The right drug, dose, agency, patient, route The right drug, dose, time, patient, route The right drug, manufacturer, time, patient, route - answer-The right drug, dose, time, patient, route Which skills would the nurse need to demonstrate according to the Quality and Safety Education for Nurses (QSEN) safety competency? Select all that apply. Uses national patient safety resources Blames others when a near-miss occurs Analyzes errors to design system improvement Relies on memory to provide quality patient care Communicates observations and concerns about hazards - answer-Uses national patient safety resources Analyzes errors to design system improvement Communicates observations and concerns about hazards In which ways is the nurse accountable for enhancing patient safety in the health care setting? Select all that apply. Provide fall risk assessments. Implement restraints only as a last measure. Prevent medication errors. Minimize or eliminate radiation exposure. Prevent procedural errors. Use safety precautions in the nurse's home environment. - answer-Provide fall risk assessments. Implement restraints only as a last measure. Prevent medication errors. Minimize or eliminate radiation exposure. Prevent procedural errors. When would the nurse assess the patient's health literacy? During the admissions process Before providing discharge teaching During each patient interaction When initiating the nursing education plan - answer-During each patient interaction Which patient behaviors could indicate low health literacy? Select all that apply. Wants to wait for family before signing consent form Has laboratory results that do not support the patient's prescribed treatment plan Refers to medications by the color of the pill Frequently misses follow-up appointments Requests family to be present at the patient care conference - answer-Wants to wait for family before signing consent form Has laboratory results that do not support the patient's prescribed treatment plan Refers to medications by the color of the pill Frequently misses follow-up appointments Which question would be most appropriate for the nurse to ask when trying to gauge the patient's current knowledge of health care needs? "Most people with heart failure take an angiotensin-converting enzyme (ACE) inhibitor. Do you take an ACE inhibitor medication for your heart failure?" "Were you prescribed diuretics for your heart failure?" "Diuretics can sometimes cause you to lose potassium. Do you eat a diet high in potassium?" "Which medications do you take for your high blood pressure?" - answer-"Which medications do you take for your high blood pressure?" An open-ended question about the patient's medications for high blood pressure helps the nurse determine whether the patient knows the names of the medications and what the medications treat. Which descriptors are accurate for an appropriately written patient education goal? Select all that apply. Discrete Specific Patient-centered Measurable Individualized - answer-Specific Patient-centered Measurable Individualized A patient in the emergency department with known supraventricular tachycardia starts experiencing shortness of breath and is no longer tolerating the dysrhythmia. Which teaching approach is most likely to be used when informing the patient about the need for cardioversion? Sensitive Telling Entrusting Participating - answer-Telling The telling approach is used when there is limited time for teaching, and specific information needs to be delivered. Because the patient's condition was deteriorating, the telling approach is most appropriate. Match the teaching approach to its description. Reinforcing, Telling, Entrusting, Participating Patient is given opportunity to manage personal care Patient and nurse are both involved in the learning process Nurse presents direct, clear, and precise information to the patient Nurse provides a stimulus that produces a desired response - answer-Patient is given opportunity to manage personal care- Entrusting Patient and nurse are both involved in the learning process- Participating Nurse presents direct, clear, and precise information to the patient- Telling Nurse provides a stimulus that produces a desired response- Reinforcing Which environmental factors are important to consider before providing patient education? Select all that apply. Space Privacy Noise Comfort Location - answer-Space Privacy Noise Comfort Which approaches have been shown to improve the understanding of difficult information? Select all that apply. Use simple words. Cover a single topic at a time. Limit information to what is most important. Use simple pictures and drawings when able. Present the information using bullet points. - answer-Use simple words. Limit information to what is most important. Use simple pictures and drawings when able. Present the information using bullet points. Which questions by the nurse would be effective for verifying that the patient has learned the information? Select all that apply. "Can you tell me three signs of heart failure?" "Do you take the medicine in the morning and at nighttime?" "When will you visit your primary health care provider next after you are discharged?" "Can you explain when you will take this medication at home?" "Do you understand what I taught you?" - answer-"Can you tell me three signs of heart failure?" "When will you visit your primary health care provider next after you are discharged?" "Can you explain when you will take this medication at home?" Which cue is an example of physiologic evidence indicating that a patient newly diagnosed with diabetes may not have understood the discharge education clearly? Patient's stating daily insulin doses incorrectly Family member's stating the patient is still eating too much sugar Consistently elevated blood glucose levels Prescription refills being picked up every 45 days - answer-Consistently elevated blood glucose levels Which patient statements could indicate a low health literacy? Select all that apply. "I don't have very good handwriting. Can I just tell you the information to write down?" "I forgot my glasses at home, and this print is just too small for me to ready clearly." "I take a blue pill in the morning and evening and a white pill every evening." "I am sorry I missed that appointment. I guess I was distracted and forgot about it." "I would like to have my family present when the physician comes to discuss my treatment options." - answer-"I don't have very good handwriting. Can I just tell you the information to write down?" "I forgot my glasses at home, and this print is just too small for me to ready clearly." "I take a blue pill in the morning and evening and a white pill every evening." "I am sorry I missed that appointment. I guess I was distracted and forgot about it." Which factors are most important in the educational assessment of an older adult patient? Select all that apply. Visual impairment Hearing limitations Cognitive ability Spiritual belief Emotional concerns - answer-Visual impairment Hearing limitations Cognitive ability Emotional concerns A 56-year-old male is undergoing emergency surgery for a ruptured appendix. The nurse gives his wife the registration paperwork and asks her to complete the forms. Which action by the spouse could be indicative of a health literacy issue? Select all that apply. Puts on her eyeglasses before beginning paperwork Asks the nurse to read the forms because she "forgot her glasses and can't read the small print" Waits for their daughter to arrive to complete the paperwork Returns the paperwork only partially completed Starts the paperwork but takes a moment to pray before completing the forms - answer-Asks the nurse to read the forms because she "forgot her glasses and can't read the small print" Waits for their daughter to arrive to complete the paperwork Returns the paperwork only partially completed The nurse is generating educational goals for her patients. Which patient educational goal is written correctly? The patient will be more accepting of the new diagnosis by time of discharge. The patient will participate in the central venous line sterile dressing change before discharge. The patient will understand the signs associated with heart failure. The patient will administer the correct dose of insulin after obtaining a blood glucose level. - answer-The patient will administer the correct dose of insulin after obtaining a blood glucose level. The nurse is providing patient education to the parents of an infant born with tetralogy of Fallot. The infant is currently stable, and surgery is planned for 3 days from now. Which teaching approach would be best for this situation? Entrusting Telling Participating Skillful - answer-Participating Participating is the approach used when both the patient and the nurse are involved in the learning process, and it would be the most appropriate in this situation. The parents are free to interrupt and ask questions as the nurse provides the medical information. A newly graduated registered nurse is creating a solution in an educational plan for a patient with heart failure. Which statement by the nurse would NOT indicate a need for further education? Select all that apply. "Specifically defined interventions clarify what the patient needs to accomplish." "The patient must be clearly identified as the one to accomplish the goal." "The desired goal must be clearly defined." "The goal can be related to increasing knowledge or learning a skill." "The action for achieving the goal should be simple and specific." - answer-"Specifically defined interventions clarify what the patient needs to accomplish." "The desired goal must be clearly defined." "The goal can be related to increasing knowledge or learning a skill." "The action for achieving the goal should be simple and specific." To promote a positive learning experience for a 75-year-old patient, which environmental concerns would the nurse address? Select all that apply. Keep the patient's door closed. Keep the door open for adequate ventilation. Ask the patient about room temperature preference. Ensure adequate lighting. Open the window to enjoy the cool breeze and fresh air. - answer-Keep the patient's door closed. Ask the patient about room temperature preference. Ensure adequate lighting. The nurse is providing discharge teaching to the parents of a child with a congenital heart defect. Which statement best presents the desired information to the parents? "Call the primary health care provider if the baby has decreased PO intake and emesis." "Call the primary health care provider if you notice the baby has tachypnea and looks mottled." "Call the primary health care provider if you notice your baby is breathing fast and refusing to breastfeed or take a bottle." "Call the primary health care provider about any signs of respiratory distress." - answer-"Call the primary health care provider if you notice your baby is breathing fast and refusing to breastfeed or take a bottle." Which nursing action would best ensure patient understanding of how to perform a dressing change in the home environment? Ask the patient to verbalize the correct steps when performing a dressing change. Clearly ask the patient, "Do you have any questions?" Assess the patient's pain level after the dressing change and before discharge. Have the patient demonstrate a correct dressing change before discharge. - answer-Have the patient demonstrate a correct dressing change before discharge. Which scenario would be the best example of an informal educational interaction with a parent while the infant is hospitalized? Leaving an informative teaching sheet for the parent at the infant's bedside Teaching about the side effects of diuretics to the parent when administering intravenous (IV) medication to the infant Verbal discussion with a parent while the infant is having an IV line placed Asking the parent to demonstrate how to check a pulse rate on the infant - answer-Teaching about the side effects of diuretics to the parent when administering intravenous (IV) medication to the infant Which outcomes are often associated with low health literacy? Select all that apply. Taking prescribed medications incorrectly Missing follow-up appointments Decreased hospital admissions Higher health care costs Poor adherence with treatment plans - answer-Taking prescribed medications incorrectly Missing follow-up appointments Higher health care costs Poor adherence with treatment plans Which patient would the nurse recognize as having the highest risk for low health literacy? A 42-year-old college educated male currently in prison A 70-year-old college professor admitted for heart failure A 25-year-old undocumented migrant worker A 16-year-old in high school with an intact family support system - answer-A 25-year-old undocumented migrant worker Which actions indicate proficiency in health literacy? Select all that apply. Being able to drive to follow-up appointments Understanding which websites are appropriate to use for health information Understanding benefits of Medicare programs Being able to call and schedule follow-up appointments Navigating a smartphone to input a medication list into an app - answer-Understanding which websites are appropriate to use for health information Understanding benefits of Medicare programs Being able to call and schedule follow-up appointments Navigating a smartphone to input a medication list into an app 1. A nurse is instructing a patient who has decreased leg strength on the left side on how to use a cane. Which actions indicate proper cane use by the patient? (Select all that apply.) 1. The patient keeps the cane on the left side of the body. 2. The patient slightly leans to one side while walking. 3. The patient keeps two points of support on the floor at all times. 4. After the patient places the cane forward, he or she then moves the right leg forward to the cane. 5. The patient places the cane forward 15 to 25 cm (6 to 10 inches) with each step. - answer-3. The patient keeps two points of support on the floor at all times. 5. The patient places the cane forward 15 to 25 cm (6 to 10 inches) with each step. 2. A patient is experiencing some problems with joint stability in the right leg. The doctor has prescribed crutches for the patient to use while being allowed to bear weight only on the left leg. Which of the following gaits should the patient be taught to use? 1. Four-point 2. Three-point 3. Two-point 4. Swing-through - answer-2. Three-point 3. Which of the following motivates a patient to participate in an exercise program? (Select all that apply.) 1. Providing a patient with a pamphlet on exercise 2. Providing information to the patient when he or she is ready to change behavior 3. Explaining the importance of exercise at the time of diagnosis of a chronic disease 4. Having a structured daily plan that incorporates physical activity 5. Having support from significant other to engage in exercise - answer-2. Providing information to the patient when he or she is ready to change behavior 4. Having a structured daily plan that incorporates physical activity 5. Having support from significant other to engage in exercise 5. The nurse is caring for an older adult in a long-term care setting. The nurse reviews the medical record to find that the patient has progressive loss of total bone mass. The patient's history and tendency to take smaller steps with feet kept closer together will most likely result in which of the following? 1. Increase the patient's risk for falls and injuries 2. Result in less stress on the patient's joints 3. Decrease the amount of work required for patient movement 4. Allow for mobility in spite of the aging effects on the patient's joints - answer-1. Increase the patient's risk for falls and injuries 6. Place in the correct order the steps needed (below) to transfer a patient with sufficient lower body strength to a chair. 1. On count of three, instruct patient to stand while straightening hips and legs and keeping knees slightly flexed. 2. Assist patient to assume proper alignment in sitting position. 3. Help patient apply stable, nonskid shoes/socks. 4. Spread your feet apart. Flex hips and knees, aligning knees with patient's knees. 5. Apply gait/transfer belt. 6. Maintain patient's balance as you pivot foot farthest from chair and then help patient ease into chair. 7. Grasp transfer belt along patient's sides. - answer-5. Apply gait/transfer belt. 3. Help patient apply stable, nonskid shoes/socks. 4. Spread your feet apart. Flex hips and knees, aligning knees with patient's knees. 7. Grasp transfer belt along patient's sides. 1. On count of three, instruct patient to stand while straightening hips and legs and keeping knees slightly flexed. 6. Maintain patient's balance as you pivot foot farthest from chair and then help patient ease into chair. 2. Assist patient to assume proper alignment in sitting position. 7. Before transferring a patient from the bed to a stretcher, which assessment data does the nurse need to gather? (Select all that apply.) 1. Patient's weight 2. Patient's activity tolerance 3. Patient's level of mobility 4. Recent laboratory values 5. Nutritional intake - answer-1. Patient's weight 2. Patient's activity tolerance 3. Patient's level of mobility 8. Which of the following indicates that additional assistance is needed to transfer a patient from the bed to the stretcher? (Select all that apply.) 1. The patient is 5 feet, 6 inches and weighs 120 lb. 2. The patient speaks and understands English. 3. The patient is returning to unit from recovery room after a procedure requiring conscious sedation. 4. The patient has a history of being able to stand independently. 5. The patient received analgesia for pain 30 minutes ago. - answer-3. The patient is returning to unit from recovery room after a procedure requiring conscious sedation. 5. The patient received analgesia for pain 30 minutes ago. 9. A 51-year-old adult comes to a medical clinic for an annual physical exam. The patient is found to be slightly overweight and reports being inactive, walking only 2 to 3 times a week with his wife after work. He has good muscle strength and coordination of lower extremities. Which of the following recommendations from the Physical Activity Guidelines for Americans should the nurse suggest? Choose all that apply 1. Move more and sit less throughout the day. 2. Participate in at least 90 minutes a week of moderate-intensity aerobic physical activity. 3. Perform muscle-strengthening activities using light weights on 2 or more days a week. 4. Walk at a vigorous pace with wife at least 150 minutes over five days a week. 5. Focus on balance training. - answer-1. Move more and sit less throughout the day. 3. Perform muscle-strengthening activities using light weights on 2 or more days a week. 4. Walk at a vigorous pace with wife at least 150 minutes over five days a week. 10. Family members have asked for a meeting with the nursing staff of an assisted-living residential center to discuss the feasibility of their mother using a walker. The family is worried that her health is declining; they wonder whether she can use the walker safely. Which of the following instructions should the nurse give the family after assessing that it is safe for the woman to use a walker? (Select all that apply.) 1. A walker is useful for patients who have impaired balance. 2. The patient uses a walker by pushing the device forward. 3. Leaning over the walker improves the patient's balance. 4. Walkers should not be used on stairs. 5. If the patient has difficulty advancing the walker, a walker with wheels is an option. - answer-1. A walker is useful for patients who have impaired balance. 4. Walkers should not be used on stairs. 5. If the patient has difficulty advancing the walker, a walker with wheels is an option. 4. Which of the following is the proper sequence for a four-point crutch gait? - answer-A) 1 1. A patient asks a nurse to provide instruction on how to perform a breast self-exam. Which domains are required to learn this skill? (Select all that apply.) 1. Affective domain 2. Sensory domain 3. Cognitive domain 4. Attentional domain 5. Psychomotor domain - answer-3. Cognitive domain 5. Psychomotor domain 2. A patient suddenly experiences a severe headache with numbness and decreased movement in the left arm. The emergency room physician suspects a stroke and is going to have the patient undergo an emergent angiogram to remove the clot. Which teaching approach is most appropriate? 1. Selling approach 2. Telling approach 3. Entrusting approach 4. Participating approach - answer-2. Telling approach 3. A nurse is caring for a young patient who has been told he has multiple sclerosis. The nurse has planned time to conduct a teaching session that will focus on the disease and principles of management. The nurse chooses to use the EDUCATE model to proceed with instruction. Which of the following are components of the model? (Select all that apply.) 1. State goals of the session for the patient. 2. Repeat the most important information. 3. Practice empathetic skills. 4. Be aware of nonverbal messages. 5. Use a standard question list for the chosen topic. - answer-2. Repeat the most important information. 3. Practice empathetic skills. 4. Be aware of nonverbal messages. 4. A nurse is teaching an older adult patient about ways to detect a melanoma. Which of the following are age-appropriate teaching techniques for this patient? (Select all that apply.) 1. Speak in a low tone. 2. Begin and end the session with the most important information regarding melanoma. 3. Provide a pamphlet about melanoma with large font in blues and greens. 4. Provide specific information in frequent, small amounts for older adult patients. 5. Speak quickly so that you do not take up much of the patient's time. - answer-1. Speak in a low tone. 2. Begin and end the session with the most important information regarding melanoma. 4. Provide specific information in frequent, small amounts for older adult patients. 5. A 55-year-old adult male has been in the hospital over a week following surgical complications. The patient has had limited activity but is now finally ordered to begin a mobility program. The patient just returned from several diagnostic tests and tells the nurse he is feeling quite fatigued. The nurse prepares to instruct the patient on the mobility program protocol. Which of the following learning principles will likely be affected by this patient's condition? 1. Motivation to learn 2. Developmental stage 3. Stage of grief 4. Readiness to learn - answer-4. Readiness to learn 6. A patient recovering from open heart surgery is taught how to cough and deep breathe using a pillow to support or splint the chest incision. Following the teaching session, which of the following is the best way for the nurse to evaluate whether learning has taken place? 1. Verbalization of steps to use in splinting 2. Selecting from a series of flash cards the images showing the correct technique 3. Return demonstration 4. Cloze test - answer-3. Return demonstration 1. Assessment 2. Communication 3. Cultural 4. Establishment 5. Sensitivity 6. Safety A. Help patients feel culturally secure and able to maintain their cultural identity. B. Remain aware of verbal and nonverbal responses. C. Be aware of how patients from diverse backgrounds perceive their care needs. D. Become aware of your patient's culture and your own cultural biases. E. Learn about the patient's health beliefs and practices. F. Show respect by creating a caring rapport. - answer-1 E 2 B 3 D 4 F 5 C 6 A 8. A 63-year-old woman is a family caregiver for her 88-year-old mother who has dementia. The caregiver asked the home health nurse how to manage her mother when she becomes confused and violent. The best instructional method a nurse can use for this situation is: 1. Demonstration 2. Preparatory instruction 3. Role-playing 4. Group instruction with other family caregivers - answer-3. Role-playing 9. A nurse is preparing to teach a patient who has sleep apnea how to use a CPAP machine at night. Which action is most appropriate for the nurse to perform first? 1. Allow patient to manipulate machine and look at parts. 2. Provide a teach-back session. 3. Set mutual goals for the education session. 4. Discuss the purpose of the machine and how it works. - answer-3. Set mutual goals for the education session. 10. Which of the following scenarios demonstrate that learning has taken place? (Select all that apply.) 1. A patient listens to a nurse's review of the warning signs of a stroke. 2. A patient describes how to set up a pill organizer for newly ordered medicines. 3. A patient attends a spinal cord injury support group. 4. A patient demonstrates how to take his blood pressure at home. 5. A patient reviews written information about resources for cancer survivors. - answer-2. A patient describes how to set up a pill organizer for newly ordered medicines. 4. A patient demonstrates how to take his blood pressure at home. 1. A patient has been on bed rest for over 5 days. Which of these findings during the nurse's assessment may indicate a complication of immobility? 1. Decreased peristalsis 2. Decreased heart rate 3. Increased blood pressure 4. Increased urinary output - answer-1. Decreased peristalsis 2. An older-adult patient has been bedridden for 2 weeks. Which of these complaints by the patient indicates to the nurse that he or she is developing a complication of immobility? 1. Increase of appetite 2. Gum soreness 3. Difficulty in swallowing 4. Left ankle joint stiffness - answer-4. Left ankle joint stiffness 3. A patient is receiving 40 mg of enoxaparin subcutaneously every 12 hours while on prolonged bed rest to prevent thrombophlebitis. Because bleeding is a potential side effect of this medication, the nurse should continually assess the patient for what signs of bleeding? (Select all that apply.) 1. Bruising 2. Pale yellow urine 3. Bleeding gums 4. Coffee ground-like vomitus 5. Light brown stool - answer-1. Bruising 3. Bleeding gums 4. Coffee ground-like vomitus 4. Place the following steps in the correct order for positioning a patient in the 30-degree lateral side-lying position. 1. Raise side rail and go to opposite side of bed. 2. Lower side rail and flex patient's knee that will not be next to mattress. Keep foot on mattress and place one hand on patient's upper bent leg near hip and other hand on shoulder. 3. Lower head of bed flat if patient can tolerate it. 4. Roll patient onto side toward you. 5. Lower side rail and position patient on side of bed opposite the direction toward which patient is to be turned. 6. Place hands under patient's dependent shoulder and bring shoulder blade forward. 7. Place hands under patient's dependent hip and bring hip slightly forward so that angle from hip to mattress is approximately 30 degrees. - answer-3, 5, 1, 2, 4, 6, 7 3. Lower head of bed flat if patient can tolerate it. 5. Lower side rail and position patient on side of bed opposite the direction toward which patient is to be turned. 1. Raise side rail and go to opposite side of bed. 2. Lower side rail and flex patient's knee that will not be next to mattress. Keep foot on mattress and place one hand on patient's upper bent leg near hip and other hand on shoulder. 4. Roll patient onto side toward you. 6. Place hands under patient's dependent shoulder and bring shoulder blade forward. 7. Place hands under patient's dependent hip and bring hip slightly forward so that angle from hip to mattress is approximately 30 degrees. 5. The effects of immobility on the cardiac system include which of the following? (Select all that apply.) 1. Thrombus formation 2. Increased cardiac workload 3. Weak peripheral pulses 4. Irregular heartbeat 5. Orthostatic hypotension - answer-1. Thrombus formation 2. Increased cardiac workload 5. Orthostatic hypotension 6. A 46-year-old patient is admitted to the emergency department following an automobile accident. The patient has a pelvic fracture and is ordered on bed rest and placed in an immobilization device to limit further injury until the fracture can safely be repaired. Which measures would be appropriate for this patient to prevent complications of bed rest? (Select all that apply.) 1. Administer intravenous analgesic as ordered. 2. Have patient perform incentive spirometry. 3. Support patient in active assistive ROM exercises of upper extremities. 4. Provide patient a low-calorie diet. 5. Apply sequential compression devices to legs. - answer-2. Have patient perform incentive spirometry. 3. Support patient in active assistive ROM exercises of upper extremities. 5. Apply sequential compression devices to legs. 7. A patient has an order for application of compression stockings. Place the following steps for application of the stockings in the correct order: 1. Place patient's toes into foot of stocking up to the heel; keep smooth. 2. Use tape measure to measure patient's leg for proper stocking size. 3. Slide stocking up over patient's calf until sock is completely extended. 4. Turn elastic stocking inside out, keeping hand inside holding heel. Take other hand and pull stocking inside out until reaching the heel. 5. Slide remaining portion of stocking over patient's foot, covering toes. Be sure foot fits into toe and heel of stocking. - answer-2, 4, 1, 5, 3 2. Use tape measure to measure patient's leg for proper stocking size. 4. Turn elastic stocking inside out, keeping hand inside holding heel. Take other hand and pull stocking inside out until reaching the heel. 1. Place patient's toes into foot of stocking up to the heel; keep smooth. 5. Slide remaining portion of stocking over patient's foot, covering toes. Be sure foot fits into toe and heel of stocking. 3. Slide stocking up over patient's calf until sock is completely extended. 8. An older-adult patient is admitted following a hip fracture and surgical repair. Before ambulating the patient postoperatively on the evening of surgery, which of the following would be most important to assess? (Select all that apply.) 1. Patient's usual dietary intake 2. Time and date of the patient's last bowel movement 3. Preadmission activity tolerance 4. Baseline heart rate 5. Patient's home living situation - answer-3. Preadmission activity tolerance 4. Baseline heart rate 9. A nurse is helping a patient perform active assisted range of motion in the right elbow. Which statement describes the correct technique? 1. Support elbow by holding distal part of extremity. 2. Grasp joint with fingers to provide support. 3. Have patient move joint independently. 4. Move the joint past the point of resistance. 5. Perform the exercise a few times only, and gradually build up to more. - answer-1. Support elbow by holding distal part of extremity. 10. A middle-aged adult patient has limited mobility following a total knee arthroplasty. During assessment, the nurse notes that the patient is having difficulty breathing while lying supine. Which assessment data support a pulmonary issue related to immobility? (Select all that apply.) 1. Oxygen saturation of 89% 2. Irregular radial pulse 3. Diminished breath sounds bilateral bases on auscultation 4. BP: 132/84 5. Pain reported at 3 on scale of 0 to 10 following medication 6. Respiratory rate of 26 - answer-1. Oxygen saturation of 89% 3. Diminished breath sounds bilateral bases on auscultation 6. Respiratory rate of 26 1. It is important to take precautions to prevent medication errors. A nurse is administering an oral tablet to a patient. Which of the following steps is the second check for accuracy in determining the patient is receiving the right medication? 1. Logging on to automated dispensing system (ADS) or unlocking medicine drawer or cart. 2. Before going to patient's room, comparing patient's name and name of medication on label of prepared drugs with MAR. 3. Selecting correct medication from ADS, unit-dose drawer, or stock supply and comparing name of medication on label with MAR or computer printout. 4. Comparing MAR or computer printout with names of medications on medication labels and patient name at patient's bedside. - answer-2. Before going to patient's room, comparing patient's name and name of medication on label of prepared drugs with MAR. 3. An older adult states that she cannot see her medication bottles clearly to determine when to take her prescription. What should the nurse do? (Select all that apply.) 1. Provide a dispensing system for each day of the week. 2. Provide larger, easier-to-read labels. 3. Tell the patient what is in each container. 4. Have a family caregiver administer the medication. 5. Use teach-back to ensure that the patient knows what medication to take and when. - answer-1. Provide a dispensing system for each day of the week. 2. Provide larger, easier-to-read labels. 5. Use teach-back to ensure that the patient knows what medication to take and when. 4. The nurse must take a verbal order during an emergency on the unit. Which of the following guidelines can be used for taking verbal or telephone orders? (Select all that apply). 1. Only authorized staff may receive and record verbal or telephone orders. The health care agency identifies in writing the staff who are authorized. 2. Clearly identify patient's name, room number, and diagnosis. 3. Read back all orders to health care provider. 4. Use clarification questions to avoid misunderstandings. 5. Write "VO" (verbal order) or "TO" (telephone order), including date and time, name of patient, and complete order; sign the name of the health care provider and nurse. - answer-1. Only authorized staff may receive and record verbal or telephone orders. The health care agency identifies in writing the staff who are authorized. 2. Clearly identify patient's name, room number, and diagnosis. 3. Read back all orders to health care provider. 4. Use clarification questions to avoid misunderstandings. 5. Write "VO" (verbal order) or "TO" (telephone order), including date and time, name of patient, and complete order; sign the name of the health care provider and nurse. 5. A nurse is administering ophthalmic ointment to a patient. Place the following steps in correct order for the administration of the ointment. 1. Clean eye, washing from inner to outer canthus. 2. Assess patient's level of consciousness and ability to follow instructions. 3. Apply thin ribbon of ointment evenly along inner edge of lower eyelid on conjunctiva. 4. Have patient close eye and rub lightly in a circular motion with a cotton ball. 5. Ask patient to look at ceiling, and explain the steps to patient. - answer-2, 1, 5, 3, 4 2. Assess patient's level of consciousness and ability to follow instructions. 1. Clean eye, washing from inner to outer canthus. 5. Ask patient to look at ceiling, and explain the steps to patient. 3. Apply thin ribbon of ointment evenly along inner edge of lower eyelid on conjunctiva. 4. Have patient close eye and rub lightly in a circular motion with a cotton ball. 6. The nurse is administering an IV push medication to a patient who has a compatible IV fluid running through intravenous tubing. Place the following steps in the appropriate order. 1. Release tubing and inject medication within amount of time recommended by agency policy, pharmacist, or medication reference manual. Use watch to time administration. 2. Select injection port of IV tubing closest to patient. Whenever possible, injection port should accept a needleless syringe. Use IV filter if required by medication reference or agency policy. 3. After injecting medication, release tubing, withdraw syringe, and recheck fluid infusion rate. 4. Connect syringe to port of IV line. Insert needleless tip or small-gauge needle of syringe containing prepared drug through center of injection port 5. Clean injection port with antiseptic swab. Allow to dry. 6. Occlude IV line by pinching tubing just above injection port. Pull b - answer-2, 5, 4, 6, 1, 3 2. Select injection port of IV tubing closest to patient. Whenever possible, injection port should accept a needleless syringe. Use IV filter if required by medication reference or agency policy. 5. Clean injection port with antiseptic swab. Allow to dry. 4. Connect syringe to port of IV line. Insert needleless tip or small-gauge needle of syringe containing prepared drug through center of injection port 6. Occlude IV line by pinching tubing just above injection port. Pull back gently on syringe plunger to aspirate blood return. 1. Release tubing and inject medication within amount of time recommended by agency policy, pharmacist, or medication reference manual. Use watch to time administration. 3. After injecting medication, release tubing, withdraw syringe, and recheck fluid infusion rate. 7. A nurse is administering a metered-dose inhaler (MDI) with a spacer to a patient with chronic obstructive pulmonary disease. Place the steps of the procedure in the correct order. 1. Insert MDI into end of spacer. 2. Perform a respiratory assessment. 3. Remove mouthpiece from MDI and spacer device. 4. Place the spacer mouthpiece into patient's mouth, and instruct patient to close lips around the mouthpiece. 5. Depress medication canister, spraying 1 puff into spacer device. 6. Shake inhaler for 2-5 seconds. 7. Instruct patient to hold breath for 10 seconds. 8. Instruct patient to breathe in slowly through mouth for 3 to 5 seconds. - answer-2, 3, 6, 1, 4, 5, 8, 7 2. Perform a respiratory assessment. 3. Remove mouthpiece from MDI and spacer device. 6. Shake inhaler for 2-5 seconds. 1. Insert MDI into end of spacer. 4. Place the spacer mouthpiece into patient's mouth, and instruct patient to close lips around the mouthpiece. 5. Depress medication canister, spraying 1 puff into spacer device. 8. Instruct patient to breathe in slowly through mouth for 3 to 5 seconds. 7. Instruct patient to hold breath for 10 seconds. 8. A patient is to receive medications through a small-bore nasogastric feeding. Which nursing actions are appropriate? (Select all that apply.) 1. Verifying tube placement after medications are given 2. Mixing all medications together to give all at once 3. Using an enteral tube syringe to administer medications 4. Flushing tube with 30 to 60 mL of water after the last dose of medication 5. Checking for gastric residual before giving the medications 6. Keeping the head of the bed elevated 30 to 60 minutes after the medications are given - answer-3. Using an enteral tube syringe to administer medications 4. Flushing tube with 30 to 60 mL of water after the last dose of medication 5. Checking for gastric residual before giving the medications 6. Keeping the head of the bed elevated 30 to 60 minutes after the medications are given 9. Place the steps of administering an intradermal injection in the correct order. 1. Inject medication slowly. 2. Note the presence of a bleb. 3. Advance needle through epidermis to 3 mm. 4. Using nondominant hand, stretch skin over site with forefinger. 5. Insert needle at a 5- to 15-degree angle into the skin until resistance is felt. 6. Cleanse site with antiseptic swab. - answer-6, 4, 5, 3, 1, 2 6. Cleanse site with antiseptic swab. 4. Using nondominant hand, stretch skin over site with forefinger. 5. Insert needle at a 5- to 15-degree angle into the skin until resistance is felt. 3. Advance needle through epidermis to 3 mm. 1. Inject medication slowly. 2. Note the presence of a bleb. 10. After receiving an intramuscular (IM) injection in the deltoid, a patient states, "My arm really hurts. It's burning and tingling where I got my injection." What should the nurse do next? (Select all that apply.) 1. Assess the injection site. 2. Administer an oral medication for pain. 3. Notify the patient's health care provider of assessment findings. 4. Document assessment findings and related interventions in the patient's medical record. 5. This is a normal finding, so nothing needs to be done. 6. Apply ice to the site for relief of burning pain. - answer-1. Assess the injection site. 3. Notify the patient's health care provider of assessment findings. 4. Document assessment findings and related interventions in the patient's medical record. 1. Which of the following are safe practices to follow in the safe preparation and storage of food? (Select all that apply.) 1. Always use a single cutting board to prepare foods for cooking. 2. Refrigerate leftovers as soon as possible. 3. Always buy vegetables in packages marked "prewashed." 4. Cook meats to the proper temperature. 5. Wash hands thoroughly before food preparation. - answer-2. Refrigerate leftovers as soon as possible. 4. Cook meats to the proper temperature. 5. Wash hands thoroughly before food preparation. 2. A nurse enters the hospital room of a patient who had a total knee replacement the day before. Which of the following pose potential safety risks? (Select all that apply.) 1. A current safety inspection sticker is on the IV fluids pump. 2. A walker is positioned near the patient's bedside. 3. The hospital bed is in the high position. 4. There is no gait belt at the bedside. 5. The overbed table with the patient's glasses is positioned against the wall opposite the end of the bed. - answer-2. A walker is positioned near the patient's bedside. 3. The hospital bed is in the high position. 5. The overbed table with the patient's glasses is positioned against the wall opposite the end of the bed. 3. A nurse working on a medicine unit in the hospital hears the fire alarm go off. As the nurse walks down the hallway, there is smoke coming from the family waiting area. Which of the following steps should the nurse take? (Select all that apply.) 1. Immediately phone in to the hospital alert system the exact location of the fire. 2. Direct the nurse technician to place empty stretchers behind the fire doors. 3. Go to each patient room, and direct ambulatory patients to walk themselves to a safe area. 4. Work with the nurse technician to help move patients requiring wheelchairs from their rooms. 5. Close the room doors of patients who cannot get out of bed, and keep them in their rooms. - answer-1. Immediately phone in to the hospital alert system the exact location of the fire. 3. Go to each patient room, and direct ambulatory patients to walk themselves to a safe area. 4. Work with the nurse technician to help move patients requiring wheelchairs from their rooms. 4. Match the threats to safety on the right to the category of risk factors on the left. A. Individual Risks B. Developmental Risks 1. An older adult has limited finances. 2. A young toddler likes to explore objects by placing them in his mouth. 3. A 55-year-old patient has a residual gait change due to a stroke. 4. A school-age child chooses to play ice hockey. 5. A patient newly diagnosed with diabetes has low health literacy. - answer-A. Individual Risks: 1. An older adult has limited finances. 3. A 55-year-old patient has a residual gait change due to a stroke. 5. A patient newly diagnosed with diabetes has low health literacy. B. Developmental Risks 2. A young toddler likes to explore objects by placing them in his mouth. 4. A school-age child chooses to play ice hockey. 5. A nurse working on a surgery floor is assigned four patients. The nurse assesses each patient, noting behaviors and physical signs and symptoms. Which of the following patients is more likely to be violent toward the nurse? 1. The first patient maintains eye contact with the nurse, is calm during the nurse's assessment, and asks questions frequently. 2. The second patient is very drowsy, loses attention span when