Nokea
The nurse is presenting an educational session on safety for parents of adolescents. Which information will the nurse include in the teaching session?
- A. Increased aggressiveness and blood spots on clothing may indicate substance abuse.
- B. Increased aggressiveness is an environmental clue that may indicate an adolescent is abusing.
- C. Adolescents need information about the effects of uncoordination on accidents.
- D. Adolescents need to be reminded to use seat belts primarily on long trips.
Correct Answer: A
Rationale: The correct answer is A. Increased aggressiveness and blood spots on clothing are potential signs of substance abuse in adolescents. This is important information for parents to be aware of as it can indicate a serious issue that needs to be addressed promptly.
Choice B is incorrect because it only partially addresses the issue by mentioning aggressiveness but does not include the specific indication of blood spots on clothing related to substance abuse.
Choice C is incorrect as it focuses on uncoordination and accidents, which is not directly related to the signs of substance abuse mentioned in the question.
Choice D is incorrect as it discusses seat belt use, which is important but not the main focus of the educational session on safety for parents of adolescents.
In summary, choice A is the correct answer because it provides crucial information about potential signs of substance abuse in adolescents, which is relevant to the safety concerns of parents.
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The nurse has placed a yellow armband on a 70-year-old patient. Which observation by the nurse will indicate the patient has an understanding of this action?
- A. The patient removes the armband to bathe.
- B. The patient wears the red nonslip footwear.
- C. The patient insists on taking a “water†pill in the evening.
- D. The patient who is allergic to penicillin asks the name of a new medicine.
Correct Answer: B
Rationale: The correct answer is B. The patient wearing the red nonslip footwear indicates an understanding of the yellow armband. This is because the yellow armband typically signifies fall risk, and wearing red nonslip footwear is a safety measure to prevent falls. The other choices are incorrect because they do not directly relate to the significance of the yellow armband. Choice A focuses on bathing, choice C on medication timing, and choice D on medication allergies, which are not directly related to fall risk.
A patient may need restraints. Which task can the nurse delegate to a nursing assistive personnel?
- A. Determining the need for restraints
- B. Assessing the patient's orientation
- C. Obtaining an order for a restraint
- D. Applying the restraint
Correct Answer: D
Rationale: The correct answer is D: Applying the restraint. The rationale is that nursing assistive personnel can perform tasks that involve direct patient care under the supervision of a nurse. Applying restraints is a task that involves following specific guidelines and does not require critical thinking or decision-making skills. Tasks A, B, and C involve assessing, determining the need, and obtaining orders for restraints, which require nursing judgment and cannot be delegated to nursing assistive personnel. Other choices are left blank as they are not relevant to the question.
During the admission assessment, the nurse assesses the patient for fall risk. Which finding will alert the nurse to an increased risk for falls?
- A. The patient is oriented.
- B. The patient takes a hypnotic.
- C. The patient walks 2 miles a day.
- D. The patient recently became widowed.
Correct Answer: B
Rationale: The correct answer is B: The patient takes a hypnotic. Patients taking hypnotic medications are at an increased risk for falls due to the sedative effects of these drugs, causing dizziness, impaired balance, and confusion. This increases the likelihood of accidents and falls.
Incorrect Choices:
A: The patient is oriented. Being oriented does not necessarily indicate a decreased risk for falls.
C: The patient walks 2 miles a day. Regular exercise is beneficial for overall health but does not directly correlate with fall risk.
D: The patient recently became widowed. While emotional distress can affect a person's well-being, it does not directly indicate an increased risk for falls.
The nurse is providing information regarding safety and accidental poisoning to a grandparent who will be taking custody of a 1-year-old grandchild. Which comment by the grandparent will cause the nurse to intervene?
- A. The number for poison control is 800-222-1222.
- B. Never induce vomiting if my grandchild drinks bleach.
- C. I should call 911 if my grandchild loses consciousness.
- D. If my grandchild eats a plant
- E. I should provide syrup of ipecac.
Correct Answer: D
Rationale: Correct Answer: D - If my grandchild eats a plant.
Rationale:
- Eating some plants can be toxic to a child, so it is important to seek medical help immediately.
- Plants can cause serious harm and even be fatal if ingested.
- The other options emphasize important safety measures: calling poison control, not inducing vomiting, and seeking emergency help if the child loses consciousness.
- Providing syrup of ipecac is outdated and not recommended anymore due to potential risks.
- Calling 911 is crucial in emergencies, but the immediate concern with plants is to seek medical advice first.
A nurse reviews the history of a newly admitted patient. Which finding will alert the nurse that the patient is at risk for falls?
- A. 55 years old
- B. 20/20 vision
- C. Urinary continence
- D. Orthostatic hypotension
Correct Answer: D
Rationale: The correct answer is D: Orthostatic hypotension. This finding puts the patient at risk for falls due to sudden drops in blood pressure when changing positions. Orthostatic hypotension can lead to dizziness, lightheadedness, and potential falls. A: Age alone does not necessarily indicate fall risk. B: Having 20/20 vision is not directly related to fall risk. C: Urinary continence does not directly indicate fall risk. Therefore, the correct choice is D as it directly correlates with an increased risk of falls.