Chapter 12: Safety My Nursing Test Banks

Chapter 12: Safety

Meiner: Gerontologic Nursing, 5th Edition

MULTIPLE CHOICE

1. Which nursing intervention best demonstrates the understanding that older adults are at increased risk for falls because of normal age-related changes?

a.

Speaking in a loud voice when warning the patient about safety hazards

b.

Turning on bright lights so the patient can see objects such as furniture

c.

Encouraging the patient to rise from a supine position slowly

d.

Advising the patient to avoid exercising painful joints

ANS: C

Older adults who lie supine and then get up quickly are likely to experience the effects of lack of tissue elasticity when the blood pressure drops and a feeling of lightheadedness develops. It is important to educate older individuals to change position slowly.

DIF: Understanding (Comprehension) REF: Page 220 OBJ: 12-4

TOP: Teaching-Learning MSC: Safe Effective Care Environment

2. An older adults risk for a fall-related injury is directly correlated to his or her ability to regain balance. To evaluate this ability, the nurse assesses the patients:

a.

inner ear for possible fluid buildup.

b.

musculoskeletal hip, ankle, and shoulder strength.

c.

large muscle strength in thighs and upper arms.

d.

gait for steadiness.

ANS: B

Older adults who lose their balance are able to right themselves to an upright position when the musculoskeletal strength of the hips, ankles, and shoulders is adequate. The inability to regain balance because of insufficient strength can result in a fall. The other options are also possibilities, but they are not as significant as hip, ankle, and shoulder strength.

DIF: Understanding (Comprehension) REF: Page 221 OBJ: 12-4

TOP: Nursing Process: Assessment MSC: Physiologic Integrity

3. The geriatric nurses decision to identify a specific patient as a falls risk is primarily based on the:

a.

presence of visual deficiencies and musculoskeletal weakness.

b.

results determined by cognitive and physiologic assessment tools.

c.

degree of frailty and functional limitation observed.

d.

inability to follow instructions and communicate effectively.

ANS: C

Research has shown that the individual with frailty and physical functional limitations is at greatest risk for falling.

DIF: Remembering (Knowledge) REF: Page 222 OBJ: 12-4

TOP: Nursing Process: Assessment MSC: Safe Effective Care Environment

4. An older adult has been diagnosed with presbyopia. To minimize the patients risk for falls, the nurse suggests:

a.

that the edges of steps be painted a contrasting color.

b.

the patient wear sunglasses when driving.

c.

the patient wear a wide-brimmed hat when spending time outdoors.

d.

hanging blinds over sunny windows.

ANS: A

If older individuals are experiencing presbyopia, a reduction in the eyes accommodation for changes in depth, such as when ascending or descending the stairs, instruction must be given for them to carefully watch door edges, curbs, and landing steps, which signal a change in height. Painting the edges of steps a contrasting color will make these depth changes more visible. The other suggestions are not related to this disorder.

DIF: Applying (Application) REF: N/A OBJ: 12-1

TOP: Teaching-Learning MSC: Safe Effective Care Environment

5. An older adult has been diagnosed with a sinus infection. To minimize the risk for a fall-related injury, the nurse teaches the patient:

a.

that there is a possibility of prodromal falls.

b.

to take her antibiotic medication with food.

c.

to recognize symptoms of fluid buildup in the middle ear.

d.

about the increased risks of falls related to normal aging.

ANS: A

Prodromal falling refers to the onset of frequent falling heralding an acute medical problem; an infectious disease typically causes this type of fall. Educating the patient regarding the most common sources of potential falls is the cornerstone of fall prevention and management. The other options do not relate directly to this condition.

DIF: Understanding (Comprehension) REF: Page 224 OBJ: 12-4

TOP: Teaching-Learning MSC: Safe Effective Care Environment

6. The nurse identifies the older adult patient at the greatest risk for a fall-related injury as the:

a.

male with a history of a vitamin deficiency.

b.

female with a diagnosis of osteoporosis.

c.

male with a cognitive deficient.

d.

female with a history of depression.

ANS: B

Serious injury from falling is more likely to occur among those with osteoporosis.

DIF: Remembering (Knowledge) REF: Page 223 OBJ: 12-4

TOP: Nursing Process: Assessment MSC: Safe Effective Care Environment

7. An older patient diagnosed with dementia has begun behaviors that increase the risk of falling. The patients son tells the nurse that physical restraints may be used. The nurse responds:

a.

Ill document that, so that the staff can use them when necessary.

b.

Physical restraints are seldom effective on patients with dementia.

c.

The staff will use physical restraints only as a last resort.

d.

There are more effective methods to use to help ensure her safety.

ANS: D

Physical restraint use does not prevent falls and therefore should never be employed for safety precautions. This is the best explanation because the nurse will then need to explain the other measures that will be taken to keep the patient safe.

DIF: Understanding (Comprehension) REF: Page 223 OBJ: 12-3

TOP: Teaching-Learning MSC: Safe Effective Care Environment

8. A patient is being discharged after hip replacement surgery. The geriatric nurse recognizes that the most effective intervention to minimize the potential of a fall injury is to:

a.

identify the most common causes of falls that the patient is likely to encounter.

b.

discuss what kind of in-home assistance the patient will need.

c.

impress the patient with the importance of being careful not to fall.

d.

educate the patient that falling is not a normal part of aging.

ANS: A

Educating the patient regarding the most common sources of potential falls is the cornerstone of fall prevention and management. The patient may or may not need home care assistance, telling the patient how important it is not to fall does not provide the patient with a plan to avoid falling, and educating the patient on normal age-related changes also does not give the patient any information on how to avoid falling.

DIF: Understanding (Comprehension) REF: Page 219 OBJ: 12-4

TOP: Nursing Process: Assessment MSC: Safe Effective Care Environment

9. A patient is diagnosed with bilateral osteoarthritis of the knees. To best address the long-term risk for falls, the nurse encourages the patient to:

a.

use assistive mobility devises when necessary.

b.

report exacerbation of symptoms promptly.

c.

add a daily walk to exercise the knees appropriately.

d.

take analgesic medication as prescribed to manage joint pain.

ANS: D

If joint pain develops and remains untreated, it can cause older adults to become sedentary or immobile. This phenomenon of disuse and muscle atrophy contributes to muscle weakness and can lead to an increase in falls. The other statements are also appropriate, but the patients pain needs to first be managed before determining if assistive devices are needed. Walking will help build strength, but the patient wont do it if it hurts too much. Reporting symptoms does not directly affect falling.

DIF: Applying (Application) REF: N/A OBJ: 12-5

TOP: Teaching-Learning MSC: Safe Effective Care Environment

10. A cognitively impaired older adult patient is a resident at a skilled nursing facility. The nurse acting as the patients advocate will consistently address the patients risk for injury issues based on:

a.

preferences generally expressed by cognitive patients.

b.

professional nursing knowledge.

c.

implementation of the less restrictive intervention.

d.

established facility policies and procedures.

ANS: D

If patients are unable to make informed choices and no family members are available, the nurse must use nursing judgment and follow an acceptable standard of care to promote safety and security that are defined and described in official policies and procedure manuals. The preferences of other patients do not indicate this patients preferences. Professional nursing knowledge can be used but must remain within the policies. Less restrictive interventions are preferable, but again actions need to conform to policy.

DIF: Understanding (Comprehension) REF: Page 228 OBJ: 12-6

TOP: Nursing Process: Implementation MSC: Safe Effective Care Environment

11. When appropriately addressing safety issues, the geriatric nurse plans the patients care plan directed by the standard of care that requires:

a.

promoting both health and wellness by assuring safety.

b.

minimizing the patients risk for physical injury while preserving autonomy.

c.

identifying safety from injury as a patient right.

d.

emphasizing beneficence as a an ethical standard of nursing care.

ANS: B

When working with older adults, the gerontologic nurse must provide a standard of care that promotes safety and prevents foreseeable accidents or injuries while also respecting individuals autonomy to make decisions. This requires a delicate balance. The other options do not address standards.

DIF: Remembering (Knowledge) REF: Page 228 OBJ: 12-6

TOP: Nursing Process: Analysis MSC: Safe Effective Care Environment

12. Which action is best to reduce burns in the home?

a.

Instruct patients to install smoke detectors,

b.

Tell patients to have their water heaters checked,

c.

Encourage patients to switch from gas to electric stoves,

d.

Teach patients not to smoke in their houses,

ANS: B

The most common cause of burns in the home for older patients is scalding from water that is too hot. Patients should either check and reset the temperature themselves or have someone do it for them. The other actions are all helpful, but scalding remains the top cause of burns in the home for this population.

DIF: Understanding (Comprehension) REF: Page 229 OBJ: 12-7

TOP: Teaching-Learning MSC: Safe Effective Care Environment

13. A patient smokes. What advice does the nurse give this patient for safety?

a.

Do not smoke inside the house.

b.

Install working smoke detectors.

c.

Only smoke during the daytime.

d.

Install carbon monoxide detectors.

ANS: A

Smoking has been related to house fires for many years. The nurse can provide many suggestions, but not smoking inside at all is the safest option. Smoke detectors work after a fire has started. Smoking during the daytime does not eliminate the possibility of falling asleep while smoking. Carbon monoxide detectors are important but not related to fire.

DIF: Applying (Application) REF: N/A OBJ: 12-7

TOP: Teaching-Learning MSC: Safe Effective Care Environment

14. The nurse assesses which patient as being at the highest risk for poisoning related to mixing garden chemicals?

a.

The patient who has Parkinson disease with hand tremors

b.

The patient who has low vision or uses magnifying glasses

c.

The patient who has hearing impairment or wears hearing aid

d.

The patient who has osteoarthritis or using a wheeled walker

ANS: A

The patient with hand tremors is at greatest risk because of the potential for inaccurate mixing and spillage.

DIF: Applying (Application) REF: N/A OBJ: 12-7

TOP: Nursing Process: Assessment MSC: Safe Effective Care Environment

15. The student asks the nurse why ground beef and other ground meat products are more likely to be contaminated and cause food-borne illness. What response by the nurse is best?

a.

Its because they are handled more.

b.

They are from cheaper cuts of meat.

c.

They are not kept cold during shipping.

d.

They are made from leftover meats.

ANS: A

Ground meat products are handled more during processing, increasing the risk of being contaminated with microbes that cause food-borne illnesses.

DIF: Understanding (Comprehension) REF: Page 231 OBJ: 12-7

TOP: Teaching-Learning MSC: Safe Effective Care Environment

16. The nurse working with older patients would assess which patient as being at highest risk for developing secondary hypothermia?

a.

The patient who has osteoarthritis and limited mobility

b.

The patient who has a raised rash on both arms

c.

The patient who drinks four alcoholic drinks a day

d.

The patient who takes furosemide (Lasix)

ANS: C

Alcohol and substance abuse increase the risk of hypothermia because of decreased awareness and impaired judgment. Four drinks a day is excessive. Skin conditions can lead to hypothermia, but the rash is confined to the arms. The other two conditions are not risk factors.

DIF: Applying (Application) REF: N/A OBJ: 12-8

TOP: Nursing Process: Assessment MSC: Safe Effective Care Environment

17.

A patient is brought to the emergency department after falling while shoveling snow. The patients core temperature is 92?0F (33.3?0C). What rewarming measures does the nurse prepare to initiate?

a.

Warm blankets

b.

Warm heating lamps

c.

Peritoneal dialysis

d.

Warmed intravenous (IV) solutions

ANS: D

A core temperature this low requires active internal rewarming. Warmed IV solutions are appropriate. Blankets and a heating lamp are appropriate for mild hypothermia. Peritoneal dialysis is reserved for severe cases with cardiac instability.

DIF: Applying (Application) REF: N/A OBJ: 12-8

TOP: Nursing Process: Analysis MSC: Physiologic Integrity

18. A nurse is watching a parade during the summer and notices an older adult looking faint and acting somewhat confused. The patient has hot dry skin. While waiting for the rescue squad, what action by the nurse is most effective?

a.

Spraying the person with a water mist

b.

Giving the person iced tea to drink

c.

Having the person sit down on the grass

d.

Pouring cold water over the persons head

ANS: A

Spraying the person with a cold-water mist will help dissipate heat, especially if the nurse then fans the person. Iced tea is a diuretic and will increase fluid loss. Having the person sit down is a good idea, as long as the person sits in the shade. Pouring cold water over the persons head is not as effective as a water spray mist.

DIF: Applying (Application) REF: N/A OBJ: 12-8

TOP: Nursing Process: Implementation MSC: Physiologic Integrity

19. The nurse teaches that which of the following is the best place to store medications?

a.

Bathroom medicine cabinet

b.

Near the kitchen sink

c.

In the laundry room

d.

In a drawer in the bedroom

ANS: D

Medications should be kept away from heat, direct sunlight, and humidity. The drawer in the bedroom is the best of the options given.

DIF: Understanding (Comprehension) REF: Page 235 OBJ: 12-7

TOP: Teaching-Learning MSC: Safe Effective Care Environment

20. The nurse working with older adults understands that which age-related condition contributes to driving safety concerns?

a.

Wearing glasses

b.

Hearing impairment

c.

Confusion

d.

Slower reflexes

ANS: D

Slower reflexes and reaction times are a normal age-related change. Wearing glasses and hearing aids should correct the underlying problem and not be a cause for concern in themselves. Confusion is not a normal age-related change.

DIF: Understanding (Comprehension) REF: Page 235 OBJ: 12-11

TOP: Nursing Process: Assessment MSC: Safe Effective Care Environment

21. A patient has had several falls ascribed to numb feet. What action by the nurse is best?

a.

Assess patient for undiagnosed diabetes.

b.

Instruct the patient on using a cane.

c.

Ensure the patient has sturdy footwear.

d.

Tell the patient to lift the feet when walking.

ANS: A

Numbness in the feet is caused by peripheral neuropathy, which is a complication of diabetes mellitus. The nurse plans to assess the patient for this condition. The other options do not address the lack of sensation to the feet.

DIF: Applying (Application) REF: N/A OBJ: 12-5

TOP: Nursing Process: Assessment MSC: Physiologic Integrity

MULTIPLE RESPONSE

1. When assessing an older adult for intrinsic risk factors for falls, the nurse is particularly interested in which of the following? (Select all that apply.)

a.

An unsteady gait when asked to walk without assistance

b.

The presence of throw rugs in the living room of the home

c.

The patients report that he wears corrective lenses

d.

An inability to see changes in height because of poor lighting

e.

Evidence of short-term memory deficiency

ANS: A, C, E

The most salient observations for intrinsic risk factors for falls relate to gait, balance, stability, and cognition. Intrinsic risk factors are a combination of age-related changes and concurrent disease. The other two options are extrinsic factors, which relate to the environment.

DIF: Remembering (Knowledge) REF: Page 220-1 OBJ: 12-4

TOP: Nursing Process: Assessment MSC: Safe Effective Care Environment

2. A patient is brought to the emergency department after an unexplained fall. What actions by the nurse are most appropriate? (Select all that apply.)

a.

Placing the patient on a cardiac monitor

b.

Obtaining a urine sample for cultures

c.

Checking a quick bedside blood glucose

d.

Assessing the patient for asthma

e.

Performing tests for orthostatic vital signs

ANS: A, B, C, D

Common causes of falls include cardiac dysrhythmias, urinary tract infection, hypoglycemia, and dehydration, so the nurse assesses for these conditions. Asthma most likely is not an issue.

DIF: Applying (Application) REF: N/A OBJ: 12-5

TOP: Nursing Process: Assessment MSC: Physiologic Integrity

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