Nokea
Tommy R., your 68-year-old patient, is at risk for falls. He has fallen 3 times in the last month. You should keep Tommy's ______________ in order to prevent him from falling again.
- A. bedside rails up at all times
- B. bed in the low position
- C. call bell within reach
- D. family members in the room at all times
Correct Answer: C
Rationale: To prevent falls, it is essential to keep the patient's call bell within reach so they can easily call for help when needed. This allows for timely assistance and can prevent falls. While low beds can reduce the severity of injuries in case of a fall, they do not prevent falls from happening. Having family members in the room at all times is not a realistic or practical solution. Side rails can actually increase the severity of falls as patients may attempt to climb over them, and using side rails as fall prevention is considered a restraint practice that can lead to entrapment and other risks.
You may also like to solve these questions
Plantar flexion can be prevented with ________________.
- A. foot soaks
- B. foot boards
- C. toenail care
- D. proper shoes
Correct Answer: B
Rationale: Plantar flexion, or foot drop, can be prevented with foot boards, special splints, and range of motion exercises. Foot boards help maintain the foot in a neutral position, preventing contractures and deformities. Foot soaks (choice A) may help with foot hygiene but do not directly prevent plantar flexion. Toenail care (choice C) is important for overall foot health but does not prevent plantar flexion. Proper shoes (choice D) are essential for foot support and comfort but do not specifically prevent plantar flexion.
Which of the following is a local sign of infection?
- A. Swelling
- B. Rapid pulse
- C. Fever
- D. High white blood count
Correct Answer: A
Rationale: A local sign of infection refers to symptoms that are specific to the area of infection. Swelling, heat, pain, and redness near the infected site are examples of local signs. In the context of infection, swelling occurs due to an accumulation of fluid and immune cells at the site of infection. Rapid pulse, fever, and high white blood count are more systemic responses to infection and not specific local signs. Rapid pulse can indicate systemic distress or sepsis, fever is a systemic response to infection, and high white blood count is a laboratory finding that suggests an immune response but is not a direct sign of infection at a specific site.
What consideration is important when caring for a female Muslim patient?
- A. Make eye contact
- B. Provide long-sleeved gowns or allow her to use her own
- C. Touch while talking
- D. Assign male caregivers when possible
Correct Answer: B
Rationale: When caring for a female Muslim patient, providing long-sleeved gowns or allowing her to use her own clothing is crucial. Most Muslim women prefer to cover their whole body, even during examinations. Offering long gowns with long sleeves or allowing the patient to use her own clothing respects her cultural and religious preferences. Making eye contact is not a common practice in some Muslim cultures, so it's important to be mindful of this and respect the patient's preferences. Touching while talking may not be culturally appropriate for some Muslim patients, so it's best to avoid it unless necessary. Assigning female caregivers is often preferred to respect the patient's modesty and religious beliefs. If a male caregiver or physician needs to interact with the patient, the patient's husband may request to be present in the room.
Which information given by a 70-year-old patient during a health history indicates to the nurse that the patient should be screened for hepatitis C?
- A. The patient had a blood transfusion in 2005
- B. The patient used IV drugs about 20 years ago
- C. The patient frequently eats in fast-food restaurants
- D. The patient traveled to a country with poor sanitation
Correct Answer: B
Rationale: The correct answer is 'The patient used IV drugs about 20 years ago.' Any patient with a history of IV drug use should be tested for hepatitis C due to the increased risk of transmission through sharing needles. Blood transfusions given after 1992, when an antibody test for hepatitis C became available, do not pose a risk for hepatitis C. Hepatitis C is not spread by the oral-fecal route, so contaminated food or traveling to countries with poor sanitation are not direct risk factors for hepatitis C.
Which risk factor places patients and residents at the greatest risk for falls?
- A. Old age
- B. Middle age
- C. Pneumonia
- D. COPD
Correct Answer: A
Rationale: Old age is a significant risk factor for falls as elderly individuals are more prone to falls due to factors like decreased balance, muscle strength, and vision. Middle age is less associated with falls compared to old age. Pneumonia and COPD are medical conditions that are not direct risk factors for falls, unlike aging which significantly increases the risk of falls.