NURS 320 - Exam 1 Practice Questions and solutions
A patient has been newly admitted to a medicine unit with a history of diabetes and advanced heart failure. The nurse is
mn mn mn mn mn mn mn mn mn mn mn mn mn mn mn mn mn mn mn mn mn
assessing the patient's fall risks. Place the following steps for measuring the "Timed Get-up and Go Test" (TUG) in the
mn mn mn mn mn mn mn mn mn mn mn mn mn mn mn mn mn mn mn mn
correct order:
mn mn
1. Have patient rise from straight-back chair without using arms for support.
mn mn mn mn mn mn mn mn mn mn mn
2. Begin timing.
mn mn
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,
mn mn mn mn mn mn mn mn mn mn mn mn mn mn mn mn mn mn mn mn mn mn mn mn
and sit down.
mn mn mn
4. Check time elapsed.
mn mn mn
5. Look for unsteadiness in patient's gait.
mn mn mn mn mn mn
6. Have patient return to chair and sit down without using arms for support. - Correct Answer ✔✔ - 3, 1, 2, 5, 6, 4.
mn mn mn mn mn mn mn mn mn mn mn mn mn mn mn mn mn mn mn mn mn mn mn mn mn mn
These are the correct steps for performing the TUG. mn mn mn mn mn mn mn mn
A nurse knows that the people most at risk for accidental hypothermia are: (Select all that apply)
mn mn mn mn mn mn mn mn mn mn mn mn mn mn mn mn
1. People who are homeless.
mn mn mn mn
2. People with respiratory conditions.
mn mn mn mn
3. People with cardiovascular conditions.
mn mn mn mn
4. The very old.
mn mn mn
5. People with kidney disorders. - Correct Answer ✔✔ - 1, 3, 4.
mn mn mn mn mn mn mn mn mn mn mn mn mn mn
Exposure to severe cold for prolonged periods causes frostbite and accidental hypothermia. Older adults, the young,
mn mn mn mn mn mn mn mn mn mn mn mn mn mn mn
patients with cardiovascular conditions, patients who have ingested drugs or alcohol in excess, and people who are
mn mn mn mn mn mn mn mn mn mn mn mn mn mn mn mn mn
homeless are at high risk for hypothermia.
mn mn mn mn mn mn mn
A parent calls the pediatrician's office to ask about directions for using a car seat. Which of the following is the most
mn mn mn mn mn mn mn mn mn mn mn mn mn mn mn mn mn mn mn mn mn
correct set of instructions the nurse gives to this parent?
mn mn mn mn mn mn mn mn mn mn
1. Only infants and toddlers need to ride in the back seat.
mn mn mn mn mn mn mn mn mn mn mn
2. All toddlers can move to a forward facing car seat when they reach age 2.
mn mn mn mn mn mn mn mn mn mn mn mn mn mn mn
3. Toddlers must reach age 2 AND the height / weight requirement before they ride forward facing.
mn mn mn mn mn mn mn mn mn mn mn mn mn mn mn mn
4. Toddlers must reach age 2 OR the height or weight requirement before they ride forward facing. - Correct Answer ✔
mn mn mn mn mn mn mn mn mn mn mn mn mn mn mn mn mn mn mn mn mn
-4
mn mn mn
The American Academy of Pediatrics (2011a) recommends that all infants and toddlers ride in the back seat with a rea
mn mn mn mn mn mn mn mn mn mn mn mn mn mn mn mn mn mn mn
facing-only seat and rear-facing convertible seat until they are 2 years of age or they reach the highest weight or height
mn mn mn mn mn mn mn mn mn mn mn mn mn mn mn mn mn mn mn mn
allowed by the manufacturer of the car safety seat.
mn mn mn mn mn mn mn mn mn
The nursing assessment of a 78 year old woman reveals orthostatic hypotension, weakness on the left side, and fear o
mn mn mn mn mn mn mn mn mn mn mn mn mn mn mn mn mn mn mn
falling. On the basis of the patient's data, which one of the following nursing diagnoses indicates an understanding of th
mn mn mn mn mn mn mn mn mn mn mn mn mn mn mn mn mn mn mn mn
assessment findings?
mn mn
1. Activity intolerance
mn mn
2. Impaired bed mobility
mn mn mn
3. Acute pain mn mn
4. Risk for falls - Correct Answer ✔✔ - 4
mn mn mn mn mn mn mn mn mn mn
For adults age 65 and older, orthostatic hypotension, fear of falling, and weakness on one side are risks for the nursing
mn mn mn mn mn mn mn mn mn mn mn mn mn mn mn mn mn mn mn mn
diagnosis of Risk for Falls.
mn mn mn mn mn
A couple who is caring for their aging parents are concerned about factors that put them at risk for falls. Which factors a
mn mn mn mn mn mn mn mn mn mn mn mn mn mn mn mn mn mn mn mn mn mn
most likely to contribute to an increase in falls in the elderly? (Select all that apply)
mn mn mn mn mn mn mn mn mn mn mn mn mn mn mn mn
,1. Inadequate lighting
mn mn
2. Throw rugs
mn mn
3. Multiple medications
mn mn
4. Doorway thresholds
mn mn
5. Cords covered by carpets
mn mn mn mn
6. Staircases with handrails - Correct Answer ✔✔ - 1,2,3,4,5
mn mn mn mn mn mn mn mn mn mn
Falls most often occur while transferring from beds, chairs, and toilets; getting into or out of bathtubs; tripping over item
mn mn mn mn mn mn mn mn mn mn mn mn mn mn mn mn mn mn mn
such as cords covered by rugs or carpets, carpet edges, or doorway thresholds; slipping on wet surfaces; and
mn mn mn mn mn mn mn mn mn mn mn mn mn mn mn mn mn mn
descending stairs. Multiple medications also contribute to fall risk.
mn mn mn mn mn mn mn mn mn
You are caring for a patient who frequently tries to remove his intravenous catheter and feeding tube. You have an orde
mn mn mn mn mn mn mn mn mn mn mn mn mn mn mn mn mn mn mn mn
from the health care provider to apply a wrist restraint. Place the steps for applying a wrist restraint in the correct order.
mn mn mn mn mn mn mn mn mn mn mn mn mn mn mn mn mn mn mn mn mn mn
1. Be sure that patient is comfortable with arm in anatomic alignment
mn mn mn mn mn mn mn mn mn mn mn
2. wrap wrist with soft part of restraint toward skin and secure snugly
mn mn mn mn mn mn mn mn mn mn mn mn
3. Identify patient using two identifiers
mn mn mn mn mn
4. Introduce self and ask patient about his feelings of being restrained
mn mn mn mn mn mn mn mn mn mn mn
5. Assess condition of skin where restraint will be placed - Correct Answer ✔✔ - 3,4,1,5,2
mn mn mn mn mn mn mn mn mn mn mn mn mn mn mn mn
The family of a patient who is confused and ambulatory insists that all four side rails be up when the patient is alone. Wh
mn mn mn mn mn mn mn mn mn mn mn mn mn mn mn mn mn mn mn mn mn mn mn
is the best action to take in this situation? (Select all that apply)
mn mn mn mn mn mn mn mn mn mn mn mn mn
1. Contact the nursing supervisor
mn mn mn mn
2. Restrict the family's visiting privileges
mn mn mn mn mn
3. Ask the family to stay with the patient if possible
mn mn mn mn mn mn mn mn mn mn
4. Inform the family of the risks associated with side-rail use
mn mn mn mn mn mn mn mn mn mn
5. Thank the family for being conscientious and put the four rails up
mn mn mn mn mn mn mn mn mn mn mn mn
6. Discuss alternatives that are appropriate for this patient with the family - Correct Answer ✔✔ - 3, 4, 6
mn mn mn mn mn mn mn mn mn mn mn mn mn mn mn mn mn mn mn mn
The family is concerned about ensuring a safe environment for their loved one. The nurse should discuss their concern
mn mn mn mn mn mn mn mn mn mn mn mn mn mn mn mn mn mn
the risk of using restraints related to using four side rails, and safer alternatives such as the presence of a family memb
mn mn mn mn mn mn mn mn mn mn mn mn mn mn mn mn mn mn mn mn mn mn
If the family still insists on use of four side rails, you could contact the nursing supervisor to further discuss the situation
mn mn mn mn mn mn mn mn mn mn mn mn mn mn mn mn mn mn mn mn mn mn
with them. This is not a reason to restrict visitation; but, although you should appreciate their concern, the use of four si
mn mn mn mn mn mn mn mn mn mn mn mn mn mn mn mn mn mn mn mn mn mn
rails should be avoided.
mn mn mn mn
You are conducting an education class at a local senior center on safe-driving tips for seniors. Which of the following
mn mn mn mn mn mn mn mn mn mn mn mn mn mn mn mn mn mn mn
should you include? (Select all that apply)
mn mn mn mn mn mn mn
1. Drive shorter distances
mn mn mn
2. Drive only during daylight hours
mn mn mn mn mn
3. Use the side and rear view mirrors carefully
mn mn mn mn mn mn mn mn
4. Keep a window rolled down while driving
mn mn mn mn mn mn mn mn
5. Look behind toward the blind spot
mn mn mn mn mn mn
6. Stop driving at age 75 - Correct Answer ✔✔ - 1,2,3,4,5
mn mn mn mn mn mn mn mn mn mn mn mn
Educate patients regarding safe driving tips (e.g., driving shorter distances or only in daylight, using side and rearview
mn mn mn mn mn mn mn mn mn mn mn mn mn mn mn mn mn
mirrors carefully, and looking behind them toward their "blind spot" before changing lanes). If hearing is a problem,
mn mn mn mn mn mn mn mn mn mn mn mn mn mn mn mn mn mn
encourage the patient to keep a window rolled down while driving or reduce the volume of the radio or CD player.
mn mn mn mn mn mn mn mn mn mn mn mn mn mn mn mn mn mn mn mn mn
Counseling is often necessary to help older patients make the decision of when to stop driving.
mn mn mn mn mn mn mn mn mn mn mn mn mn mn mn mn
The nursing assessment of an 80 year old patient who demonstrates some confusion but no anxiety revels that the
mn mn mn mn mn mn mn mn mn mn mn mn mn mn mn mn mn mn
patient is a fall risk because she continues to get out of bed without help despite frequent reminders. The initial nursing
mn mn mn mn mn mn mn mn mn mn mn mn mn mn mn mn mn mn mn mn mn
intervention to prevent falls for this patient is to:
mn mn mn mn mn mn mn mn mn
1. Place a bed alarm device on the bed.
mn mn mn mn mn mn mn mn
2. Place the patient in a belt restraint.
mn mn mn mn mn mn mn mn
,3. Provide one-on-one observation of the patient.
mn mn mn mn mn mn
4. Apply wrist restraints - Correct Answer ✔✔ - 1
mn mn mn mn mn mn mn mn mn mn
Consider and implement alternatives as appropriate before the use of a restraint. A bed alarm is an alternative that the
mn mn mn mn mn mn mn mn mn mn mn mn mn mn mn mn mn mn mn
nurse implements independently.
mn mn mn
A nurse is evaluating a patient who is in soft wrist restrains. Which of the following activities does the nurse perform?
mn mn mn mn mn mn mn mn mn mn mn mn mn mn mn mn mn mn mn mn
(select all that apply)
mn mn mn mn
1. Check the patient's peripheral pulse in the restrained extremity
mn mn mn mn mn mn mn mn mn mn
2. Evaluate the patient's need for toileting
mn mn mn mn mn mn
3. Offer the patient fluids if appropriate
mn mn mn mn mn mn
4. Release both limbs at the same time to perform range of motion (ROM)
mn mn mn mn mn mn mn mn mn mn mn mn mn
5. Inspect the skin under each restraint - Correct Answer ✔✔ - 1, 2, 3, 5
mn mn mn mn mn mn mn mn mn mn mn mn mn mn mn mn
The nurse should evaluate patient for signs of injury every 15 minutes (e.g., circulation, vital signs, ROM, physical and
mn mn mn mn mn mn mn mn mn mn mn mn mn mn mn mn mn mn
psychological status, and readiness for discontinuation. The nurse should evaluate patient's need for toileting, nutritio
mn mn mn mn mn mn mn mn mn mn mn mn mn mn mn
and fluids, hygiene, and elimination and release restraint at least every 2 hours but should do it one limb at a time.
mn mn mn mn mn mn mn mn mn mn mn mn mn mn mn mn mn mn mn mn mn mn
You are admitting Mr. Jones, a 64 year old patient who had a right hemisphere stroke and a recent fall. His wife states th
mn mn mn mn mn mn mn mn mn mn mn mn mn mn mn mn mn mn mn mn mn mn mn
he has a history of high blood pressure, which is controlled by an anti hypertensive and a diuretic. Currently he exhibits
mn mn mn mn mn mn mn mn mn mn mn mn mn mn mn mn mn mn mn mn mn
left-sided neglect and problems with spatial and perceptual abilities and is impulsive. He has moderate left-sided
mn mn mn mn mn mn mn mn mn mn mn mn mn mn mn mn
weakness that requires the assistance of two and the use of a gait belt to transfer to a chair. He currently has an
mn mn mn mn mn mn mn mn mn mn mn mn mn mn mn mn mn mn mn mn mn mn mn
intravenous (IV) line and a urinary catheter in place. Which factors increase his fall risk at this time? (Select all that app
mn mn mn mn mn mn mn mn mn mn mn mn mn mn mn mn mn mn mn mn mn mn
1. Smokes a pack a day
mn mn mn mn mn
2. Used a cane to walk at home
mn mn mn mn mn mn mn
3. Takes antihypertensive and diuretics
mn mn mn mn
4. History of recent fall
mn mn mn mn
5. Neglect, spatial and perceptual abilities, impulsive
mn mn mn mn mn mn
6. Requires assistance with activity, unsteady gait
mn mn mn mn mn mn
7. IV line, urinary catheter - Correct Answer ✔✔ - 3, 4, 5, 6, 7.
mn mn mn mn mn mn mn mn mn mn mn mn mn mn mn mn
Smoking is not a risk factor for falls. Use of the cane at home is not a current risk factor for falls. Risk is determined by his
mn mn mn mn mn mn mn mn mn mn mn mn mn mn mn mn mn mn mn mn mn mn mn mn mn mn
current status.
mn mn
At 12 noon the emergency department nurse hears that an explosion has occurred in a local manufacturing plant. Whi
mn mn mn mn mn mn mn mn mn mn mn mn mn mn mn mn mn mn
action does the nurse take first?
mn mn mn mn mn mn
1. Prepare for an influx of patients
mn mn mn mn mn mn
2. Contact the American red Cross
mn mn mn mn mn
3. Determine how to resume normal operations
mn mn mn mn mn mn
4. Evacuate patients per the disaster plan - Correct Answer ✔✔ - 1
mn mn mn mn mn mn mn mn mn mn mn mn mn
The emergency department nurse needs to prepare for the potential influx of patients first. Staff need to be aware of the
mn mn mn mn mn mn mn mn mn mn mn mn mn mn mn mn mn mn mn mn
disaster plan. Patients may need to be evaluated but not initially. The American Red Cross is not contacted initially.
mn mn mn mn mn mn mn mn mn mn mn mn mn mn mn mn mn mn mn
Determination of how to resume normal operations is part of the disaster plan and is determined before an actual even
mn mn mn mn mn mn mn mn mn mn mn mn mn mn mn mn mn mn mn mn
The nurse is caring for a patient who is having a seizure. Which of the following measures will protect the patient and th
mn mn mn mn mn mn mn mn mn mn mn mn mn mn mn mn mn mn mn mn mn mn
nurse from injury? (Select all that apply)
mn mn mn mn mn mn mn
1. If patient is standing, attempt to get him or her back to bed
mn mn mn mn mn mn mn mn mn mn mn mn mn
2. With patient on floor, clear surrounding area of furniture or equipment
mn mn mn mn mn mn mn mn mn mn mn
3. If possible keep patient lying supine
mn mn mn mn mn mn
4. Do not restrain mn mn mn
patient; hold limbs loosely if they are flailing
mn mn mn mn mn mn mn mn
5. Never force apart a patient's clenched teeth - Correct Answer ✔✔ - 2, 4, 5
mn mn mn mn mn mn mn mn mn mn mn mn mn mn mn mn
A patient has been newly admitted to a medicine unit with a history of diabetes and advanced heart failure. The nurse is
mn mn mn mn mn mn mn mn mn mn mn mn mn mn mn mn mn mn mn mn mn
assessing the patient's fall risks. Place the following steps for measuring the "Timed Get-up and Go Test" (TUG) in the
mn mn mn mn mn mn mn mn mn mn mn mn mn mn mn mn mn mn mn mn
correct order:
mn mn
1. Have patient rise from straight-back chair without using arms for support.
mn mn mn mn mn mn mn mn mn mn mn
2. Begin timing.
mn mn
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,
mn mn mn mn mn mn mn mn mn mn mn mn mn mn mn mn mn mn mn mn mn mn mn mn
and sit down.
mn mn mn
4. Check time elapsed.
mn mn mn
5. Look for unsteadiness in patient's gait.
mn mn mn mn mn mn
6. Have patient return to chair and sit down without using arms for support. - Correct Answer ✔✔ - 3, 1, 2, 5, 6, 4.
mn mn mn mn mn mn mn mn mn mn mn mn mn mn mn mn mn mn mn mn mn mn mn mn mn mn
These are the correct steps for performing the TUG. mn mn mn mn mn mn mn mn
A nurse knows that the people most at risk for accidental hypothermia are: (Select all that apply)
mn mn mn mn mn mn mn mn mn mn mn mn mn mn mn mn
1. People who are homeless.
mn mn mn mn
2. People with respiratory conditions.
mn mn mn mn
3. People with cardiovascular conditions.
mn mn mn mn
4. The very old.
mn mn mn
5. People with kidney disorders. - Correct Answer ✔✔ - 1, 3, 4.
mn mn mn mn mn mn mn mn mn mn mn mn mn mn
Exposure to severe cold for prolonged periods causes frostbite and accidental hypothermia. Older adults, the young,
mn mn mn mn mn mn mn mn mn mn mn mn mn mn mn
patients with cardiovascular conditions, patients who have ingested drugs or alcohol in excess, and people who are
mn mn mn mn mn mn mn mn mn mn mn mn mn mn mn mn mn
homeless are at high risk for hypothermia.
mn mn mn mn mn mn mn
A parent calls the pediatrician's office to ask about directions for using a car seat. Which of the following is the most
mn mn mn mn mn mn mn mn mn mn mn mn mn mn mn mn mn mn mn mn mn
correct set of instructions the nurse gives to this parent?
mn mn mn mn mn mn mn mn mn mn
1. Only infants and toddlers need to ride in the back seat.
mn mn mn mn mn mn mn mn mn mn mn
2. All toddlers can move to a forward facing car seat when they reach age 2.
mn mn mn mn mn mn mn mn mn mn mn mn mn mn mn
3. Toddlers must reach age 2 AND the height / weight requirement before they ride forward facing.
mn mn mn mn mn mn mn mn mn mn mn mn mn mn mn mn
4. Toddlers must reach age 2 OR the height or weight requirement before they ride forward facing. - Correct Answer ✔
mn mn mn mn mn mn mn mn mn mn mn mn mn mn mn mn mn mn mn mn mn
-4
mn mn mn
The American Academy of Pediatrics (2011a) recommends that all infants and toddlers ride in the back seat with a rea
mn mn mn mn mn mn mn mn mn mn mn mn mn mn mn mn mn mn mn
facing-only seat and rear-facing convertible seat until they are 2 years of age or they reach the highest weight or height
mn mn mn mn mn mn mn mn mn mn mn mn mn mn mn mn mn mn mn mn
allowed by the manufacturer of the car safety seat.
mn mn mn mn mn mn mn mn mn
The nursing assessment of a 78 year old woman reveals orthostatic hypotension, weakness on the left side, and fear o
mn mn mn mn mn mn mn mn mn mn mn mn mn mn mn mn mn mn mn
falling. On the basis of the patient's data, which one of the following nursing diagnoses indicates an understanding of th
mn mn mn mn mn mn mn mn mn mn mn mn mn mn mn mn mn mn mn mn
assessment findings?
mn mn
1. Activity intolerance
mn mn
2. Impaired bed mobility
mn mn mn
3. Acute pain mn mn
4. Risk for falls - Correct Answer ✔✔ - 4
mn mn mn mn mn mn mn mn mn mn
For adults age 65 and older, orthostatic hypotension, fear of falling, and weakness on one side are risks for the nursing
mn mn mn mn mn mn mn mn mn mn mn mn mn mn mn mn mn mn mn mn
diagnosis of Risk for Falls.
mn mn mn mn mn
A couple who is caring for their aging parents are concerned about factors that put them at risk for falls. Which factors a
mn mn mn mn mn mn mn mn mn mn mn mn mn mn mn mn mn mn mn mn mn mn
most likely to contribute to an increase in falls in the elderly? (Select all that apply)
mn mn mn mn mn mn mn mn mn mn mn mn mn mn mn mn
,1. Inadequate lighting
mn mn
2. Throw rugs
mn mn
3. Multiple medications
mn mn
4. Doorway thresholds
mn mn
5. Cords covered by carpets
mn mn mn mn
6. Staircases with handrails - Correct Answer ✔✔ - 1,2,3,4,5
mn mn mn mn mn mn mn mn mn mn
Falls most often occur while transferring from beds, chairs, and toilets; getting into or out of bathtubs; tripping over item
mn mn mn mn mn mn mn mn mn mn mn mn mn mn mn mn mn mn mn
such as cords covered by rugs or carpets, carpet edges, or doorway thresholds; slipping on wet surfaces; and
mn mn mn mn mn mn mn mn mn mn mn mn mn mn mn mn mn mn
descending stairs. Multiple medications also contribute to fall risk.
mn mn mn mn mn mn mn mn mn
You are caring for a patient who frequently tries to remove his intravenous catheter and feeding tube. You have an orde
mn mn mn mn mn mn mn mn mn mn mn mn mn mn mn mn mn mn mn mn
from the health care provider to apply a wrist restraint. Place the steps for applying a wrist restraint in the correct order.
mn mn mn mn mn mn mn mn mn mn mn mn mn mn mn mn mn mn mn mn mn mn
1. Be sure that patient is comfortable with arm in anatomic alignment
mn mn mn mn mn mn mn mn mn mn mn
2. wrap wrist with soft part of restraint toward skin and secure snugly
mn mn mn mn mn mn mn mn mn mn mn mn
3. Identify patient using two identifiers
mn mn mn mn mn
4. Introduce self and ask patient about his feelings of being restrained
mn mn mn mn mn mn mn mn mn mn mn
5. Assess condition of skin where restraint will be placed - Correct Answer ✔✔ - 3,4,1,5,2
mn mn mn mn mn mn mn mn mn mn mn mn mn mn mn mn
The family of a patient who is confused and ambulatory insists that all four side rails be up when the patient is alone. Wh
mn mn mn mn mn mn mn mn mn mn mn mn mn mn mn mn mn mn mn mn mn mn mn
is the best action to take in this situation? (Select all that apply)
mn mn mn mn mn mn mn mn mn mn mn mn mn
1. Contact the nursing supervisor
mn mn mn mn
2. Restrict the family's visiting privileges
mn mn mn mn mn
3. Ask the family to stay with the patient if possible
mn mn mn mn mn mn mn mn mn mn
4. Inform the family of the risks associated with side-rail use
mn mn mn mn mn mn mn mn mn mn
5. Thank the family for being conscientious and put the four rails up
mn mn mn mn mn mn mn mn mn mn mn mn
6. Discuss alternatives that are appropriate for this patient with the family - Correct Answer ✔✔ - 3, 4, 6
mn mn mn mn mn mn mn mn mn mn mn mn mn mn mn mn mn mn mn mn
The family is concerned about ensuring a safe environment for their loved one. The nurse should discuss their concern
mn mn mn mn mn mn mn mn mn mn mn mn mn mn mn mn mn mn
the risk of using restraints related to using four side rails, and safer alternatives such as the presence of a family memb
mn mn mn mn mn mn mn mn mn mn mn mn mn mn mn mn mn mn mn mn mn mn
If the family still insists on use of four side rails, you could contact the nursing supervisor to further discuss the situation
mn mn mn mn mn mn mn mn mn mn mn mn mn mn mn mn mn mn mn mn mn mn
with them. This is not a reason to restrict visitation; but, although you should appreciate their concern, the use of four si
mn mn mn mn mn mn mn mn mn mn mn mn mn mn mn mn mn mn mn mn mn mn
rails should be avoided.
mn mn mn mn
You are conducting an education class at a local senior center on safe-driving tips for seniors. Which of the following
mn mn mn mn mn mn mn mn mn mn mn mn mn mn mn mn mn mn mn
should you include? (Select all that apply)
mn mn mn mn mn mn mn
1. Drive shorter distances
mn mn mn
2. Drive only during daylight hours
mn mn mn mn mn
3. Use the side and rear view mirrors carefully
mn mn mn mn mn mn mn mn
4. Keep a window rolled down while driving
mn mn mn mn mn mn mn mn
5. Look behind toward the blind spot
mn mn mn mn mn mn
6. Stop driving at age 75 - Correct Answer ✔✔ - 1,2,3,4,5
mn mn mn mn mn mn mn mn mn mn mn mn
Educate patients regarding safe driving tips (e.g., driving shorter distances or only in daylight, using side and rearview
mn mn mn mn mn mn mn mn mn mn mn mn mn mn mn mn mn
mirrors carefully, and looking behind them toward their "blind spot" before changing lanes). If hearing is a problem,
mn mn mn mn mn mn mn mn mn mn mn mn mn mn mn mn mn mn
encourage the patient to keep a window rolled down while driving or reduce the volume of the radio or CD player.
mn mn mn mn mn mn mn mn mn mn mn mn mn mn mn mn mn mn mn mn mn
Counseling is often necessary to help older patients make the decision of when to stop driving.
mn mn mn mn mn mn mn mn mn mn mn mn mn mn mn mn
The nursing assessment of an 80 year old patient who demonstrates some confusion but no anxiety revels that the
mn mn mn mn mn mn mn mn mn mn mn mn mn mn mn mn mn mn
patient is a fall risk because she continues to get out of bed without help despite frequent reminders. The initial nursing
mn mn mn mn mn mn mn mn mn mn mn mn mn mn mn mn mn mn mn mn mn
intervention to prevent falls for this patient is to:
mn mn mn mn mn mn mn mn mn
1. Place a bed alarm device on the bed.
mn mn mn mn mn mn mn mn
2. Place the patient in a belt restraint.
mn mn mn mn mn mn mn mn
,3. Provide one-on-one observation of the patient.
mn mn mn mn mn mn
4. Apply wrist restraints - Correct Answer ✔✔ - 1
mn mn mn mn mn mn mn mn mn mn
Consider and implement alternatives as appropriate before the use of a restraint. A bed alarm is an alternative that the
mn mn mn mn mn mn mn mn mn mn mn mn mn mn mn mn mn mn mn
nurse implements independently.
mn mn mn
A nurse is evaluating a patient who is in soft wrist restrains. Which of the following activities does the nurse perform?
mn mn mn mn mn mn mn mn mn mn mn mn mn mn mn mn mn mn mn mn
(select all that apply)
mn mn mn mn
1. Check the patient's peripheral pulse in the restrained extremity
mn mn mn mn mn mn mn mn mn mn
2. Evaluate the patient's need for toileting
mn mn mn mn mn mn
3. Offer the patient fluids if appropriate
mn mn mn mn mn mn
4. Release both limbs at the same time to perform range of motion (ROM)
mn mn mn mn mn mn mn mn mn mn mn mn mn
5. Inspect the skin under each restraint - Correct Answer ✔✔ - 1, 2, 3, 5
mn mn mn mn mn mn mn mn mn mn mn mn mn mn mn mn
The nurse should evaluate patient for signs of injury every 15 minutes (e.g., circulation, vital signs, ROM, physical and
mn mn mn mn mn mn mn mn mn mn mn mn mn mn mn mn mn mn
psychological status, and readiness for discontinuation. The nurse should evaluate patient's need for toileting, nutritio
mn mn mn mn mn mn mn mn mn mn mn mn mn mn mn
and fluids, hygiene, and elimination and release restraint at least every 2 hours but should do it one limb at a time.
mn mn mn mn mn mn mn mn mn mn mn mn mn mn mn mn mn mn mn mn mn mn
You are admitting Mr. Jones, a 64 year old patient who had a right hemisphere stroke and a recent fall. His wife states th
mn mn mn mn mn mn mn mn mn mn mn mn mn mn mn mn mn mn mn mn mn mn mn
he has a history of high blood pressure, which is controlled by an anti hypertensive and a diuretic. Currently he exhibits
mn mn mn mn mn mn mn mn mn mn mn mn mn mn mn mn mn mn mn mn mn
left-sided neglect and problems with spatial and perceptual abilities and is impulsive. He has moderate left-sided
mn mn mn mn mn mn mn mn mn mn mn mn mn mn mn mn
weakness that requires the assistance of two and the use of a gait belt to transfer to a chair. He currently has an
mn mn mn mn mn mn mn mn mn mn mn mn mn mn mn mn mn mn mn mn mn mn mn
intravenous (IV) line and a urinary catheter in place. Which factors increase his fall risk at this time? (Select all that app
mn mn mn mn mn mn mn mn mn mn mn mn mn mn mn mn mn mn mn mn mn mn
1. Smokes a pack a day
mn mn mn mn mn
2. Used a cane to walk at home
mn mn mn mn mn mn mn
3. Takes antihypertensive and diuretics
mn mn mn mn
4. History of recent fall
mn mn mn mn
5. Neglect, spatial and perceptual abilities, impulsive
mn mn mn mn mn mn
6. Requires assistance with activity, unsteady gait
mn mn mn mn mn mn
7. IV line, urinary catheter - Correct Answer ✔✔ - 3, 4, 5, 6, 7.
mn mn mn mn mn mn mn mn mn mn mn mn mn mn mn mn
Smoking is not a risk factor for falls. Use of the cane at home is not a current risk factor for falls. Risk is determined by his
mn mn mn mn mn mn mn mn mn mn mn mn mn mn mn mn mn mn mn mn mn mn mn mn mn mn
current status.
mn mn
At 12 noon the emergency department nurse hears that an explosion has occurred in a local manufacturing plant. Whi
mn mn mn mn mn mn mn mn mn mn mn mn mn mn mn mn mn mn
action does the nurse take first?
mn mn mn mn mn mn
1. Prepare for an influx of patients
mn mn mn mn mn mn
2. Contact the American red Cross
mn mn mn mn mn
3. Determine how to resume normal operations
mn mn mn mn mn mn
4. Evacuate patients per the disaster plan - Correct Answer ✔✔ - 1
mn mn mn mn mn mn mn mn mn mn mn mn mn
The emergency department nurse needs to prepare for the potential influx of patients first. Staff need to be aware of the
mn mn mn mn mn mn mn mn mn mn mn mn mn mn mn mn mn mn mn mn
disaster plan. Patients may need to be evaluated but not initially. The American Red Cross is not contacted initially.
mn mn mn mn mn mn mn mn mn mn mn mn mn mn mn mn mn mn mn
Determination of how to resume normal operations is part of the disaster plan and is determined before an actual even
mn mn mn mn mn mn mn mn mn mn mn mn mn mn mn mn mn mn mn mn
The nurse is caring for a patient who is having a seizure. Which of the following measures will protect the patient and th
mn mn mn mn mn mn mn mn mn mn mn mn mn mn mn mn mn mn mn mn mn mn
nurse from injury? (Select all that apply)
mn mn mn mn mn mn mn
1. If patient is standing, attempt to get him or her back to bed
mn mn mn mn mn mn mn mn mn mn mn mn mn
2. With patient on floor, clear surrounding area of furniture or equipment
mn mn mn mn mn mn mn mn mn mn mn
3. If possible keep patient lying supine
mn mn mn mn mn mn
4. Do not restrain mn mn mn
patient; hold limbs loosely if they are flailing
mn mn mn mn mn mn mn mn
5. Never force apart a patient's clenched teeth - Correct Answer ✔✔ - 2, 4, 5
mn mn mn mn mn mn mn mn mn mn mn mn mn mn mn mn
