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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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A home health nurse is teaching a family to prevent electrical shock. Which information will the nurse include in the teaching session?
- A. Run wires under the carpet.
- B. Disconnect items before cleaning.
- C. Grasp the cord when unplugging items.
- D. Use masking tape to secure cords to the floor.
Correct Answer: B
Rationale: The correct answer is B: Disconnect items before cleaning. This is the safest way to prevent electrical shock as it ensures that no electrical current is flowing through the items being cleaned. Running wires under the carpet (A) can create a tripping hazard and increase the risk of damage to the wires. Grasping the cord when unplugging items (C) can lead to accidental contact with live wires. Using masking tape to secure cords to the floor (D) can damage the cords and increase the risk of tripping. Therefore, disconnecting items before cleaning is the most effective way to prevent electrical shock.
Which patient will the nurse see first?
- A. A 56-year-old patient with oxygen with a lighter on the bedside table
- B. A 56-year-old patient with oxygen using an electric razor for grooming
- C. A 1-month-old infant looking at a shiny
- D. round battery just out of arm's reach
- E. A 1-month-old infant with a pacifier that has no string around the baby's neck
Correct Answer: B
Rationale: The nurse will see patient B first because using an electric razor near oxygen can lead to a fire hazard due to the presence of flammable gases. Patient A with a lighter poses a similar risk, but using an electric razor is more immediate. Patient C and D present no immediate danger. Patient E is safe as there is no strangulation risk with the pacifier. Prioritizing safety is crucial in patient care.
The nurse is discussing threats to adult safety with a college group. Which statement by a group member indicates understanding of the topic?
- A. Smoking even at parties is not good for my body.
- B. Our campus is safe; we leave our dorms unlocked all the time.
- C. As long as I have only two drinks, I can still be the designated driver.
- D. I am young, so I can work nights and go to school with 2 hours' sleep.
Correct Answer: A
Rationale: Correct Answer: A
Rationale:
1. Smoking is a significant threat to adult safety, increasing the risk of various health issues.
2. The statement acknowledges the harmful effects of smoking even in social settings, showing awareness of health risks.
3. It demonstrates understanding of personal responsibility for one's health and safety.
Summary:
B: Leaving dorms unlocked poses a safety risk, indicating a lack of understanding of safety concerns.
C: Drinking and driving, even with only two drinks, is unsafe and illegal, showing a lack of awareness.
D: Working nights with minimal sleep can lead to fatigue-related accidents, reflecting poor judgment on safety.
Which activity will cause the nurse to monitor for equipment-related accidents?
- A. Uses a patient-controlled analgesic pump
- B. Uses a computer-based documentation record
- C. Uses a measuring device that measures urine
- D. Uses a manual medication-dispensing device
Correct Answer: A
Rationale: The correct answer is A because using a patient-controlled analgesic pump involves complex equipment that can malfunction or be misused, leading to potential accidents like overmedication or pump failure. Monitoring is crucial to prevent harm. Choices B and C involve routine equipment use without high risk for accidents. Choice D is more straightforward and less prone to accidents compared to the complex analgesic pump.
The nurse is completing an admission history on a new home health patient. The patient has been experiencing seizures as the result of a recent brain injury. Which interventions should the nurse utilize for this patient and family? (Select all that apply.)
- A. Demonstrate how to restrain the patient in the event of a seizure.
- B. Instruct the family to move the patient to a bed during a seizure.
- C. Teach the family how to insert a tongue depressor during the seizure.
- D. Discuss with the family steps to take if the seizure does not discontinue.
- E. Instruct the family to reorient and reassure the patient after consciousness is regained.
Correct Answer: D, E
Rationale: The correct answers are D and E.
For choice D, it is essential to discuss steps to take if the seizure does not stop as it ensures the family is prepared and knows when to seek medical help. This is crucial for the safety of the patient.
For choice E, instructing the family to reorient and reassure the patient after regaining consciousness helps provide emotional support and comfort, promoting a sense of security and reducing anxiety post-seizure.
Choices A, B, and C are incorrect as they involve unsafe practices that can harm the patient. Restraining the patient during a seizure can lead to injury, moving the patient during a seizure can also cause harm, and inserting a tongue depressor is not recommended during a seizure as it can obstruct the airway.
Therefore, choices D and E are the most appropriate interventions for the patient and family in this scenario.