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