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The patient applies sequential compression devices after going to the bathroom. The nurse checks the patient's application of the devices and finds that they have been put on upside down. Which nursing diagnosis will the nurse add to the patient's plan of care?
- A. Risk for falls
- B. Deficient knowledge
- C. Risk for suffocation
- D. Impaired physical mobility
Correct Answer: B
Rationale: Correct Answer: B - Deficient knowledge
Rationale: The nurse's assessment indicates that the patient lacks the knowledge to properly apply the sequential compression devices, leading to them being put on upside down. This nursing diagnosis reflects the patient's need for education on device application to prevent potential harm.
Summary of other choices:
A: Risk for falls - Not directly related to the incorrect application of sequential compression devices.
C: Risk for suffocation - Not relevant to the situation described.
D: Impaired physical mobility - Incorrect application of devices does not necessarily indicate impaired physical mobility.
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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.
The nurse is performing the 'Timed Get Up and Go (TUG)' assessment. Which actions will the nurse take? (Select all that apply.)
- A. Ranks a patient as high risk for falls after patient takes 18 seconds to complete.
- B. Teaches patient to rise from a straight back chair using arms for support.
- C. Instructs the patient to walk 10 feet as quickly and safely as possible.
- D. Observes for unsteadiness in patient's gait.
- E. Begins counting after the instructions.
Correct Answer: C,D,F
Rationale: The correct answers are C, D, and F.
C: Instructing the patient to walk 10 feet quickly and safely is a key component of the TUG test to assess mobility and fall risk.
D: Observing for unsteadiness in the patient's gait is important to evaluate balance and stability during the test.
F: Beginning counting after giving instructions ensures an accurate timing of the patient's performance.
Incorrect choices:
A: Ranking a patient as high risk for falls after taking 18 seconds is not accurate as the cutoff time for increased fall risk is typically 12-14 seconds.
B: Teaching the patient to rise from a straight back chair using arms for support is not part of the TUG assessment and may not provide accurate information about the patient's mobility and fall risk.
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.
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.
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: Correct Answer: B - The patient wears the red nonslip footwear.
Rationale: The yellow armband typically signifies fall risk in healthcare settings. By wearing red nonslip footwear, the patient demonstrates understanding of the fall risk and the importance of preventing falls. This indicates a good comprehension of the armband's purpose and the need for safety precautions.
Other Choices:
A: The patient removing the armband to bathe does not demonstrate understanding of its significance in preventing falls.
C: Insisting on taking a 'water' pill in the evening is unrelated to the purpose of the yellow armband.
D: Asking about a new medicine when allergic to penicillin does not show understanding of the armband's purpose.