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The nurse is assessing a patient who reports a previous fall and is using the SPLATT acronym. Which questions will the nurse ask the patient? (Select all that apply.)
- A. Where did you fall?
- B. What time did the fall occur?
- C. What were you doing when you fell?
- D. What types of injuries occurred after the fall?
- E. Did you obtain an electronic safety alert device after the fall?
- F. What are your medical problems that may have caused the fall?
Correct Answer: A, B, C, D
Rationale: The correct answers are A, B, C, and D. The SPLATT acronym stands for Symptoms, Previous falls, Location, Activity, Time, and Trauma. Therefore, the nurse should ask where the fall happened (A), what the patient was doing when they fell (C), and what types of injuries occurred after the fall (D) to assess the circumstances surrounding the fall. Asking about the time of the fall (B) helps determine if there are any time-related factors contributing to the fall. These questions provide crucial information for assessing the patient's risk factors and potential interventions. Choices E and F are incorrect because they do not directly pertain to the SPLATT components and may not provide as relevant information for assessing the fall risk in this situation.
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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 because increased aggressiveness and blood spots on clothing are potential signs of substance abuse in adolescents. Aggressiveness and physical changes can indicate underlying issues like substance abuse, which is crucial for parents to recognize for intervention. B is incorrect because aggressiveness alone is not a definitive clue for substance abuse. C is incorrect as it focuses on uncoordination rather than specific signs of substance abuse. D is incorrect as it is a general safety reminder and not specific to substance abuse indicators.
A home health nurse is performing a home assessment for safety. Which comment by the patient will cause the nurse to follow up?
- A. Every December is the time to change batteries on the carbon monoxide detector.
- B. I will schedule an appointment with a chimney inspector next week.
- C. If I feel dizzy when using the heater, I need to have it inspected.
- D. When it is cold outside in the winter, I will use a nonvented furnace.
Correct Answer: D
Rationale: The correct answer is D because using a nonvented furnace can lead to carbon monoxide poisoning. Carbon monoxide is a colorless, odorless gas that can be deadly if inhaled in high concentrations. The other choices demonstrate good safety practices such as changing batteries on detectors, scheduling chimney inspections, and recognizing symptoms of heater issues. Using a nonvented furnace is the only unsafe practice mentioned, hence requiring immediate follow-up to educate the patient on the dangers of carbon monoxide poisoning.
A patient is admitted and is placed on fall precautions. The nurse teaches the patient and family about fall precautions. Which action will the nurse take?
- A. Check on the patient once a shift.
- B. Encourage visitors in the early evening.
- C. Place all four side rails in the 'up' position.
- D. Keep the patient on fall risk until discharge.
Correct Answer: D
Rationale: The correct answer is D because keeping the patient on fall risk until discharge ensures continuous monitoring and implementation of fall precautions. Checking on the patient once a shift (Option A) is not enough for a high fall risk patient. Encouraging visitors in the early evening (Option B) may distract the patient and increase the risk of falls. Placing all four side rails in the 'up' position (Option C) can lead to entrapment and is not recommended. Keeping the patient on fall risk until discharge (Option D) ensures consistent vigilance and preventive measures.
A nurse is inserting a urinary catheter. Which technique will the nurse use to prevent a procedure-related accident?
- A. Pathogenic asepsis
- B. Medical asepsis
- C. Surgical asepsis
- D. Clean asepsis
Correct Answer: C
Rationale: The correct answer is C: Surgical asepsis. During urinary catheter insertion, surgical asepsis is crucial to prevent infection and other procedure-related accidents. Surgical asepsis involves using sterile techniques to minimize the risk of introducing pathogens. The nurse will follow strict protocols such as wearing sterile gloves, using sterile equipment, and maintaining a sterile field. This technique ensures that the urinary catheter is inserted in a sterile environment, reducing the risk of infection. Pathogenic asepsis (A) focuses on destroying pathogens, not preventing their entry during a procedure. Medical asepsis (B) aims to reduce the number of pathogens but does not provide the level of sterility needed for urinary catheter insertion. Clean asepsis (D) involves cleanliness but does not meet the sterile requirements of urinary catheter insertion.
A confused patient is restless and continues to remove oxygen cannula and urinary catheter. What is the priority nursing diagnosis and intervention?
- A. Risk for injury: Check on patient every 15 minutes.
- B. Risk for suffocation: Place “Oxygen in Use†sign.
- C. Disturbed body image: Encourage patient expression.
- D. Deficient knowledge: Explain oxygen therapy.
Correct Answer: A
Rationale: The correct answer is A: Risk for injury: Check on patient every 15 minutes. This is the priority nursing diagnosis because the patient is at risk for harm due to removing essential medical equipment. Continuous monitoring can prevent potential injuries. Choice B is incorrect as simply placing a sign does not actively address the patient's behavior. Choice C is incorrect as the patient's actions are not related to body image. Choice D is incorrect as the patient's behavior is not due to a lack of knowledge about oxygen therapy. Monitoring the patient closely is crucial in ensuring their safety and preventing harm in this situation.