Nokea
During the admission assessment, the nurse assesses the patient for fall risk. Which finding will alert the nurse to an increased risk for falls?
- A. The patient is oriented.
- B. The patient takes a hypnotic.
- C. The patient walks 2 miles a day.
- D. The patient recently became widowed.
Correct Answer: B
Rationale: The correct answer is B: The patient takes a hypnotic. Patients taking hypnotic medications are at an increased risk for falls due to the sedative effects of these drugs, causing dizziness, impaired balance, and confusion. This increases the likelihood of accidents and falls.
Incorrect Choices:
A: The patient is oriented. Being oriented does not necessarily indicate a decreased risk for falls.
C: The patient walks 2 miles a day. Regular exercise is beneficial for overall health but does not directly correlate with fall risk.
D: The patient recently became widowed. While emotional distress can affect a person's well-being, it does not directly indicate an increased risk for falls.
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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.
The patient has been diagnosed with a respiratory illness and reports shortness of breath. The nurse adjusts the temperature to facilitate the comfort of the patient. At which temperature range will the nurse set the thermostat?
- A. 60° to 64° F
- B. 65° to 75° F
- C. 15° to 17° C
- D. 25° to 28° C
Correct Answer: B
Rationale: The correct answer is B: 65° to 75° F. This temperature range is ideal for a patient experiencing respiratory distress as it helps maintain a comfortable environment without being too cold or too warm. Lower temperatures (choice A) can exacerbate breathing difficulties, while the temperature range in Celsius (choice C) is too low for comfort. The temperature range in choice D is too warm and may cause discomfort for the patient. It is important to maintain a moderate temperature to assist the patient in breathing comfortably.
The nurse is trying to use alternatives rather than restrain a patient. Which finding will cause the nurse to determine the alternative is working?
- A. The patient continues to get up from the chair at the nurses' station.
- B. The patient gets restless when the sitter leaves for lunch.
- C. The patient folds three washcloths over and over.
- D. The patient apologizes for being 'such a bother.'
Correct Answer: C
Rationale: The correct answer is C because the patient folding three washcloths over and over indicates engagement in a task, showing decreased restlessness or agitation. This behavior suggests the patient is able to focus on a repetitive and soothing activity, indicating successful use of alternatives to restraint. Choice A shows continued restlessness, choice B demonstrates dependence on the sitter, and choice D indicates the patient's emotional response, none of which directly reflect the effectiveness of the alternative intervention.
A patient is admitted and is placed on fall precautions. The nurse teaches the patient and family about fall precautions. Which action will the nurse take?
- A. Check on the patient once a shift.
- B. Encourage visitors in the early evening.
- C. Place all four side rails in the 'up' position.
- D. Keep the patient on fall risk until discharge.
Correct Answer: D
Rationale: The correct answer is D: Keep the patient on fall risk until discharge. This is because fall precautions should be maintained throughout the patient's stay to ensure their safety. Checking on the patient once a shift (A) may not be sufficient to prevent falls. Encouraging visitors in the early evening (B) could distract the patient and increase fall risk. Placing all four side rails in the 'up' position (C) can lead to entrapment or injury. Therefore, the best practice is to keep the patient on fall risk until discharge to maintain a high level of vigilance and prevent falls effectively.
A home health nurse is performing a home assessment for safety. Which comment by the patient will cause the nurse to follow up?
- A. Every December is the time to change batteries on the carbon monoxide detector.
- B. I will schedule an appointment with a chimney inspector next week.
- C. If I feel dizzy when using the heater, I need to have it inspected.
- D. When it is cold outside in the winter, I will use a nonvented furnace.
Correct Answer: D
Rationale: The correct answer is D. Using a nonvented furnace can lead to carbon monoxide poisoning, posing a significant safety risk. This choice stands out as it directly contradicts safety measures by using a potentially hazardous heating source. Choice A demonstrates awareness of changing carbon monoxide detector batteries timely. Choice B indicates proactivity in chimney maintenance. Choice C shows understanding of seeking help if necessary. Choices E, F, and G are irrelevant. In summary, choice D is the only one that poses a direct safety concern, making it the correct answer.