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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.
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The nurse is caring for an older-adult patient admitted with nausea, vomiting, and diarrhea due to food poisoning. Which priority concern will require collaboration with social services to address the patient's health care needs?
- A. The electricity was turned off 3 days ago.
- B. The water comes from the county water supply.
- C. A son and family recently moved into the home.
- D. This home is not furnished with a microwave oven.
Correct Answer: A
Rationale: The correct answer is A. The priority concern that requires collaboration with social services is the electricity being turned off 3 days ago. This is crucial because without electricity, the patient's access to essential medical devices, such as a refrigerator for storing medications or a nebulizer for breathing treatments, is compromised. Social services can help address this issue by connecting the patient with resources for utility assistance or temporary housing.
Choice B is incorrect because access to county water supply is not directly related to the patient's immediate health care needs in this scenario. Choice C is also incorrect as the son and family moving in is not a priority concern requiring collaboration with social services. Choice D is not a priority concern either, as the lack of a microwave oven does not impact the patient's health care needs significantly.
The nurse is teaching a group of older adults at an assisted-living facility about age-related physiological changes affecting safety. Which question would be most important for the nurse to ask this group?
- A. Are you able to hear the tornado sirens in your area?
- B. Are you able to read your favorite book?
- C. Are you able to taste spices like before?
- D. Are you able to open a jar of pickles?
Correct Answer: A
Rationale: The correct answer is A: "Are you able to hear the tornado sirens in your area?" This is the most important question because hearing loss is a common age-related physiological change that can affect safety, especially during emergencies like tornadoes. The ability to hear warning signals is crucial for timely response and ensuring the safety of older adults. Choices B, C, and D are not as critical for safety concerns compared to the ability to hear warning sirens. Older adults may use aids for reading, cooking, or opening jars, but compromised hearing can directly impact their ability to respond to emergencies effectively.
The nurse is providing safety information regarding accidental poisoning to a grandparent. Which comment requires nurse intervention?
- A. The poison control number is 800-222-1222.
- B. Never induce vomiting if bleach is ingested.
- C. I should call 911 if my grandchild loses consciousness.
- D. If my grandchild eats a plant, I should provide syrup of ipecac.
Correct Answer: D
Rationale: The correct answer is D because providing syrup of ipecac to induce vomiting is no longer recommended for poisoning treatment. The American Academy of Pediatrics advises against the use of syrup of ipecac due to potential harm and lack of proven benefit. Inducing vomiting can cause further harm and delay appropriate medical treatment. A, B, and C are correct choices as they emphasize important safety measures such as contacting poison control, avoiding inducing vomiting for bleach ingestion, and calling 911 if the grandchild loses consciousness.
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 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. This technique involves creating and maintaining a sterile field to prevent contamination during invasive procedures like catheter insertion. The nurse will use sterile gloves, drapes, and equipment to minimize the risk of infection. Pathogenic asepsis (A) focuses on removing or destroying pathogens but may not ensure sterility. Medical asepsis (B) aims to reduce the number of pathogens but does not achieve a sterile environment. Clean asepsis (D) involves cleanliness but not the level of sterility required for invasive procedures.