Q UALITY
Fundamentals of Nursing 10th Edition; Potter Perry
MULTIPLE CHOICE
1. A client who is experiencing a generalized clonic -tonic seizure is at
greatest risk for injury caused by:
A. The physical collapse that occurs at the onset of the seizure
B. Muscle strains that result from the severe muscle jerking during the
seizure
C. The tongue laceration that occurs from jaw clenching during the
seizure
D. Aspiration resulting from the temporary loss of consciousness after
the seizure
ANS: A
During a fall, or as a result of muscle jerking, musculoskeletal injuries
can occur. The fall is the most problematic since is occurs in the vast
majorit y of the seizure events.
PTS: 1 DIF: C REF: 817 OBJ: Anal ysis TOP: Nursing
Process: Assessment MSC: NC LEX test plan designation:
Safe, Effective Care Environment/Safet y & Infection Control
,2. Which of the following clients is at greatest risk for injury related to
medical diagnoses and conditions?
A. A history of asthma and alcohol abuse
B. A history of heart failure and urinary urgency
C. A history of hypertension and wearing corrective lenses
D. A history of chronic bronchitis and impaired hearing
ANS: B
This client is likel y using diuretics that increase the frequency of
voiding and result in the client having to use toilet facilities more
often. Falls often occur with clients who have to get out of bed quickl y
because of urinary urgency.
PTS: 1 DIF: C REF: 817 OBJ: Anal ysis TOP: Nursing
Process: Assessment MSC: NC LEX test plan designation:
Safe, Effective Care Environment/Safet y & Infection Control
3. The nurse is conducting an admission interview and assessment on a
cognitivel y impaired, uncooperative client for the risk for injury. Which
of the following options will most likel y provide the in formation to
confirm the diagnosis?
A. Base the degree of risk on observable data at the time of the clients
current hospital admission.
B. Closel y monitor the clients behavior and habits until risk for injury
can be reasonabl y determined.
C. Make certain criticall y sound assumptions are based on the clients
developmental stage and current cognitive stasis.
D. Interview the clients famil y, friends, and/or caregivers regarding
prehospitalization risk factors.
, ANS: D
In many cases famil y members are important resources in assessing a
clients fall risk. Families often are able to report on the clients level of
confusion and abilit y to ambulate.
PTS: 1 DIF: C REF: 818 OBJ: Anal ysis TOP: Nursing
Process: Assessment MSC: NC LEX test plan designation:
Safe, Effective Care Envi ronment/Safet y & Infection Control
4. A nurse working in an acute care facilit y’s emergency department should
recognize which of the following client reports as being most suspicious
of a terrorist attack?
A. Four deaths resulting from a privatel y-owned airplane crashing into
a four-story building
B. Numerous reports of respiratory distress among older adults who
attended an outdoor musical event
C. 15 cases of nausea and vomiting reported over a 2 -day period when
4 cases would be within normal for the facilit y
D. 10 children, all who attended a child -oriented arts and crafts fair,
presenting with rashes on their hands and faces
ANS: C
An unusual increase in the number of people seeking care, especiall y
with fever, respiratory, or gastrointestinal complaints, is a classic
indicator of such an event. While the other options present possible
indicators, there are other possible reasons for the incidents.
, PTS: 1 DIF: C REF: 820 OBJ: Anal ysis TOP: Nursing
Process: Assessment MSC: NC LEX test plan designation:
Safe, Effective C are Environment/Safet y & Infection Control
5. The nurse is discussing safet y issues with the mother of three children.
Which of the following statements has the greatest possibilit y for
decreasing the potential for injury among the children?
A. Where do you see a need for safet y improvements in your home?
B. Keep all toxic liquids capped and stored out of reach of the
children.
C. Installing safet y gates at the top and bottom of each set of stairs
will help minimize falls.
D. Take great care to keep the children away fro m kitchen appliances
and tools that can hurt them.
ANS: A
Clients generall y expect to be safe in their homes and health care
settings. However, there are times when a clients view of what is safe
does not agree with that of the nurse. For this reason, any assessment
needs to include the clients understanding of his or her perception of
risk factors. The remaining options are directed toward specific safet y
issues.
PTS: 1 DIF: C REF: 824 OBJ: Anal ysis TOP: Nursing
Process: Planning MSC: NC LEX test plan des ignation: Safe,
Effective Care Environment/Safet y & Infection Control
6. The nurse recognizes that the greatest benefit of engaging the mother of
two small children into a discussion about child -proofing her home is that: