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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.
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An older-adult patient is using a wheelchair to attend a physical therapy session. Which action by the nurse indicates safe transport of the patient?
- A. Positions patient's buttocks close to the front of wheelchair seat
- B. Backs wheelchair into elevator
- C. leading with large rear wheels first
- D. Places locked wheelchair on same side of bed as patient's weaker side
- E. Unlocks wheelchair for easy maneuverability when patient is transferring
Correct Answer: B
Rationale: The correct answer is B: Backs wheelchair into elevator. This action ensures that the patient is facing forward during transport, reducing the risk of injury. Positioning the patient's buttocks close to the front of the wheelchair seat (Choice A) may cause instability. Leading with large rear wheels first (Choice C) can lead to tipping. Placing a locked wheelchair on the same side of the bed as the patient's weaker side (Choice D) may hinder safe transfer. Unlocking the wheelchair for easy maneuverability (Choice E) is important but not specifically related to safe transport.
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 question is most important as hearing loss is a common age-related physiological change that can affect safety during emergencies. Tornado sirens are crucial for alerting individuals to seek shelter.
Summary of other choices:
B: Reading ability is important but not directly related to safety.
C: Taste changes are common with age but do not impact safety significantly.
D: Difficulty opening jars may occur with age but is not as critical for safety in emergencies.
In this context, asking about hearing the tornado sirens is the most relevant question for ensuring the safety of older adults in an assisted-living facility.
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?
Correct Answer: A,B,C,D
Rationale: The correct answers are A, B, C, and D. Asking where, when, and what the patient was doing during the fall helps to assess the circumstances leading to the fall and potential risk factors. Inquiring about types of injuries provides insight into the severity of the fall and any complications. Choice E is incorrect as it focuses on post-fall actions rather than the fall event itself. The other choices, F and G, are not provided in the question and are therefore irrelevant.
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.
The patient is confused
- A. trying to get out of bed
- B. and pulling at the IV tubing. Which nursing diagnosis will the nurse add to the care plan?
- C. Impaired home maintenance
- D. Deficient knowledge
- E. Risk for poisoning
- F. Risk for injury
Correct Answer: D
Rationale: The correct answer is D: Deficient knowledge. The patient's confusion and behavior suggest a lack of understanding regarding the importance of staying in bed and not pulling at the IV tubing. By selecting this nursing diagnosis, the nurse can address the patient's cognitive deficits and provide education to prevent potential harm. Choice A is incorrect as it describes a behavior related to confusion, not a nursing diagnosis. Choice B focuses on the patient's actions rather than the underlying issue of knowledge deficit. Choices C, E, and F are not directly related to the patient's confusion and do not address the root cause of the behavior.