Chapter 13: Promoting Safety My Nursing Test Banks

Chapter 13: Promoting Safety

Test Bank

MULTIPLE CHOICE

1. Which one of the following is a true statement about mobility and safety for older adults?

a.

Use of restraints on older patients helps prevent injuries from falls.

b.

Falls that do not cause physical injury are not significant.

c.

The get-up-and-go test provides a measure of a patients energy and initiative.

d.

Lowering the bed and fluorescent tapes are interventions to increase safety.

ANS: D

Adjusting the bed height to match the length of the residents lower leg and marking the path from the bed to the toilet with bright fluorescent tape are some of the many possible interventions to improve residents safety. Restraints have not been shown to increase safety and may contribute to morbidity and mortality. Even if a fall does not cause injury, it can contribute to the fear of falling, inhibiting activities of daily living. The Get-Up-and-Go test, in which the person rises from a straight-backed chair, walks 10 feet, returns, and sits down, assesses balance and gait.

PTS: 1 DIF: Understand REF: 200| 207-208| 213-214

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

2. The nurse can place an older adult into one of four patient rooms. Which is the most suitable room for an older adult?

a.

Brightly lit, blue room with cozy throw rugs

b.

Room with orange carpeting and soft lighting

c.

Brightly lit, blue room with waxed vinyl floors

d.

Room for television and childrens playtime

ANS: B

The soft lighting avoids glare, and the carpet provides better traction than a glossy floor. Lamps should be added to supply more light when desired. Throw rugs easily slip, and older adults can trip on them, resulting in injury. The patients feet should not be able to glide easily across the floor, and when the surface becomes wet, a waxed floor can be very slippery. The patient may stumble over children and toys.

PTS: 1 DIF: Apply REF: 206-207 TOP: Nursing Process: Planning

MSC: Safe, Effective Care Environment

3. Which of the following is a true statement about assistive devices to aid older adults with impaired mobility?

a.

A walker can be used when climbing stairs.

b.

Cane tips should be smooth.

c.

Older adults save money by adapting assistive devices from their friends.

d.

A cane is most useful for unilateral disabilities but not bilateral problems.

ANS: D

Canes can relieve stress on arthritic joints on one side. A walker can equally relieve pressure on joints on both sides. Cane tips should be flat on the bottom with a series of rings, not smooth. Older adults are tempted to save money by using assistive devices from nonmedical sources; however, regardless of the source of the assistive device, the device should be fitted to the older adult. An older adult should never try to adapt to the assistive device; an ill-fitted device can contribute to falls and injuries. Using a walker is contraindicated when climbing stairs. Improperly selected or improperly used assistive devices can be risk factors for falling.

PTS:1DIF:UnderstandREF:207-210

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

4. The overall temperature in your gerontological unit is 62 F during the evening shift. In documenting this concern to the administration, which factor is the most important for the health and well-being of older adults?

a.

It is not fair for older adults to have to deal with an uncomfortable environment.

b.

Some of the residents are wearing blankets around their shoulders to keep warm.

c.

An ambient temperature of 62 F is unsuitable for older people because they have impaired thermoregulation.

d.

It feels much warmer in the administration wing than out in the patient care areas.

ANS: C

Under no circumstances should the temperature drop below 65 F because older adults are at risk for hypothermia. Furthermore, frail older adults need the temperature to be considerably higher. The issue is not one of fairness but a more fundamental issue of patient safety. Some of the residents wearing blankets may represent individual temperature preferences. The purpose is to make the point that the patients are vulnerable to low temperatures, not to make veiled accusations against the administrators.

PTS: 1 DIF: Apply REF: 215| 218 TOP: Nursing Process: Planning

MSC: Safe, Effective Care Environment

5. Which of the following statements is true about a safe, effective care environment for older adults?

a.

Cold beer with steak and potatoes is a good meal for an older adult on a hot day.

b.

Older drivers are more likely to be in a fatal motor vehicle accident than younger drivers.

c.

Barrier-free buses and low fares make public transit a safe transportation option.

d.

A nurses perception of temperature is a useful guide for patient thermal needs.

ANS: B

Although older adults have safer driving habits (e.g., less night driving, less driving in heavy traffic, shorter distances, less speeding or drunk driving) than younger drivers, the physical and sensory changes of aging contribute to a higher incidence of fatal accidents for older adults. Hot, heavy meals and alcohol should be avoided when ambient temperatures exceed 90 F. The fear of crime often deters older adults from using public transit. The older adults perception of temperature is the important factor.

PTS:1DIF:UnderstandREF:219-221

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

6. The health care provider has not ordered the use of a restraint for an alert patient at high risk for falling. The nurse should implement which side rail use?

a.

Two full-length rails

b.

One -length rail

c.

No side rails

d.

Four -length rails

ANS: B

The use of one -length rail is not considered a restraint; it can be used to assist the patient in getting in and out of bed. Two full-length rails and four -length rails would be considered a restraint. The use of no side rails is not considered a restraint; however, the use of one rail to maneuver in and out of bed may be most beneficial to the patient.

PTS: 1 DIF: Apply REF: 211 TOP: Nursing Process: Planning

MSC: Safe, Effective Care Environment

7. After assessing the older man in his bed, the nurse determines that he is at high risk for falls. The nurse leaves the room to get a fall risk sign and returns to find him on the floor pleading for help. Which of the following was the most important intervention the nurse should have implemented to prevent this event?

a.

Call for someone to bring the sign.

b.

Show the older man how to use the call bell.

c.

Provide a urinal and drinking water.

d.

Instruct the patient to call for help.

ANS: D

The nurse accomplished the most important aspect of fall prevention with the assessment. However, in an attempt to communicate the fall risk to other staff members, the nurse failed to communicate properly to the patient about fall prevention before leaving the room. Calling for someone to bring the sign would have been a reasonable approach to communicating the risk of falls, but it does not take the place of directly instructing the patient about prevention. The needs of an older adult can contribute to the risk of falls as an individual leans and reaches for something; therefore call bell instructions are a reasonable approach for preventing falls. However, before providing the call bell instructions, the nurse needed to tell him to call for help. A urinal and drinking water are common items that an older man needs, but reaching for them can contribute to falls.

PTS: 1 DIF: Analyze REF: 215 TOP: Nursing Process: Evaluation

MSC: Safe, Effective Care Environment

8. An older man was oriented and responded appropriately in the hospital, but he is now disoriented and confused in his home after discharge. Which of the following issues is the first that the home nurse should examine to determine whether an environmental issue is contributing to the patients condition at home?

a.

Complaints of shivering

b.

Temperature of household

c.

Types of food preparation

d.

Presence of radon

ANS: B

Older adults are at higher risk of hypothermia in the community because hypothermia is difficult to detect and because, as hypothermia sets in, the older adult can respond to a lower temperature. This man has clinical indicators of hypothermia; therefore the home care nurse first assesses the ambient temperature for a baseline determination because the household temperature should have the most profound impact on his body temperature. Asking about shivering can be ineffective with an older adult who is confused and disoriented; the response can be incorrect. However, to display respect, the nurse should ask the question. The type of food preparation can offer additional clues about the older adults hypothermia and mental status; if he is eating cold foods such as sandwiches and yogurt, then he can be unwittingly contributing to the problem. Presence of radon in the home may lead to lung cancer, not confusion.

PTS:1DIF:AnalyzeREF:215-218

TOP: Nursing Process: Assessment MSC: Health Promotion and Maintenance

9. The nurse assesses the quality of which of the following patient characteristics when applying the Get-Up-and-Go test from the Hendrich II Fall Risk Model?

a.

Stride

b.

Speed

c.

Balance

d.

Flexibility

ANS: C

Using the Get-Up-and-Go test, the quality of the older adults movements is assessed. The nurse instructs the individual to rise from a chair, walk, and return to the chair and be seated. The stride is not specifically assessed in this test, although it is an aspect of gait and can be a factor in balance. The older adults speed is not assessed in this test. Flexibility is not specifically assessed in this test, although it can be an important factor in balance.

PTS:1DIF:UnderstandREF:203-205

TOP: Nursing Process: Assessment MSC: Health Promotion and Maintenance

10. An older woman who receives intravenous (IV) fluids is making wide gesticulations with her arms and loudly insulting the nursing staff. Which intervention should the nurse implement to maintain safe, effective nursing care initially?

a.

Apply bilateral upper extremity restraints.

b.

Administer haloperidol (Haldol) for agitation.

c.

Close the door to her room to reduce the noise.

d.

Determine the patients needs.

ANS: D

To help maintain her independence and permit the administration of IV fluids yet provide safe, effective care, the nurse should determine what the patient is attempting to convey and then address those needs.  Restraining one side creates a potential threat from the other arm to the integrity of the IV, but bilateral restraints can be justified for the protection of the IV site. However, as a first step, the nurse should determine if the patient has a need that has not been met before moving to a restraint.

Administering an antipsychotic agent can be justified for agitation but not in this patient. Less intrusive measures are available for initial protective measures. Although nurses tend to keep the doors of patients and residents rooms slightly ajar to maintain privacy, closing this womans door is contraindicated to control noise because it can contribute to the risk of falls and injury and does nothing to maintain the integrity of the IV.

PTS: 1 DIF: Analyze REF: 211-215 TOP: Nursing Process: Planning

MSC: Safe, Effective Care Environment

11. The nurse determines that an older adult who has chronic bronchitis is at high risk for falls, but he repeatedly tries to ambulate without assistance. Which alternative measure to restraints is contraindicated for this older adult?

a.

Inform the staff about his risk for falls.

b.

Place a concave mattress on the bed.

c.

Provide frequent walks in the hallway.

d.

Help him learn to use an assistive device.

ANS: B

A concave mattress is a restraint alternative, but it is contraindicated for this patient who has chronic bronchitis because lowering the relative position of his torso in relationship to the head and lower extremities places extra pressure on the diaphragm and restricts chest expansion, which makes the work of breathing significantly more difficult for him and is contraindicated because chronic bronchitis is an obstructive breathing disorder. Communicating the risk for falls is a suitable alternative measure to restraints for him; it employs multiple people to observe, manage, and lower his fall risk. Providing frequent walks can be an effective restraint alternative for this older adult if he is restless or bored. Finally, the nurse can help him learn how to use an assistive device to help avoid the use of restraints.

PTS: 1 DIF: Apply REF: 211-215 TOP: Nursing Process: Evaluation

MSC: Safe, Effective Care Environment

12. The nurse wants to use exercise according to the recommendations of the American Geriatrics Society (AGS) for an older woman who lost her balance and fell. Which nursing intervention is suitable for this older adult according to the AGS?

a.

Tell her to use an assistive device until her balance improves.

b.

Provide information on group exercises for balance training.

c.

Help her to learn how to exercise the core group of muscles.

d.

Instruct her to enroll in an exercise program for 8 weeks.

ANS: B

The AGS states that group exercises can be effective to improve balance as part of a fall prevention program for older adults. Using an assistive device can help prevent falls; however, assistive devices are not part of an exercise program. Although the AGS states that the relationship between exercise and reducing the risk for falls is strong, the recommended type, duration, and intensity of the exercises are not clear. The AGS states that to improve balance with exercise, an older adult must participate in exercise for at least 10 weeks.

PTS:1DIF:ApplyREF:205

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

13. The nurse is discharging an older woman who uses a walker from rehabilitative care. Which observation does the nurse use to determine whether the patient is prepared for discharge?

a.

She holds the front of the walker.

b.

She has a walker with four wheels.

c.

She takes four steps into the walker.

d.

She takes the walker to the elevator.

ANS: D

The older adult uses the elevator to travel between floors of a building, demonstrating that she knows not to use a walker on the stairs and is thus safe to discharge. Older adults should use the arms of a walker for stability. A walker with four wheels can be easy to move; however, such ease of movement does not provide enough stability to be suitable as an assistive device. To use a walker correctly, she should take two steps at a time into the walker.

PTS: 1 DIF: Apply REF: 201-206 TOP: Nursing Process: Evaluation

MSC: Safe, Effective Care Environment

MULTIPLE RESPONSE

1. The nurse plans care to prevent a dangerous thermal environment for an older man who lives in a northern climate of the United States. Which patient assessment data does the nurse recognize that can contribute to his risk of hypothermia? (Select all that apply.)

a.

Has a history of a cerebrovascular accident (CVA)

b.

Has a history of diabetes mellitus

c.

Builds miniature cars for a hobby

d.

Bathes three to four times a week

e.

Gets heat from a boiler in the cellar

f.

Becomes diaphoretic on warm days

ANS: A, B, C, E

A CVA can impair an older adults thermoregulatory center and potentially diminish the individuals awareness of temperature changes or the ability to respond suitably to a temperature change. In addition, if the older adult is left with a cognitive deficit or aphasia, then the older adults ability to communicate a thermal problem is potentially impaired. A history of diabetes mellitus can contribute to a dangerous thermal environment for the older adult. A complication of diabetes is peripheral neuropathy, which potentially impairs the ability to sense temperature change. In addition, peripheral arterial disease associated with diabetes contributes to the individuals ability to compensate to temperature changes with vasodilation or vasoconstriction. Building miniature cars is a sedentary activity. The associated metabolic activity is low, the older adult generates less heat from metabolic activity, and the individual is at a higher risk for hypothermia when the temperature is cool. Household heat from a boiler in the cellar creates a potential regulatory problem for the older adult living in the building because adjustments to temperature affect the entire household and are only made in the cellar. Thermostats in individual rooms do not exist in such a heating system. If the individual has impaired mobility, then he might be unable to navigate the stairs to the cellar and adjust the temperature. Bathing three to four times a week limits the exposure of bare skin to the cooling effects of evaporation to reduce the risk of hypothermia. Diaphoresis on a warm day is a suitable response to heat.

PTS:1DIF:ApplyREF:215-218

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

2. The nurse will be educating a group of senior citizens on adaptations for safer driving. Which adaptation(s) should the nurse include? (Select all that apply.)

a.

Wide rear-view mirrors

b.

Pedal extensions

c.

Global positioning system (GPS) devices

d.

Antiroll bars

ANS: A, B, C

Wide rear-view mirrors, pedal extensions, and GPS devices are all suggested adaptations. The use of antiroll bars has not been identified as an adaptation.

PTS: 1 DIF: Remember REF: 221 TOP: Nursing Process: Planning

MSC: Safe, Effective Care Environment

3. Which of the following is(are) assessed in a fall prevention assessment of an older adult? (Select all that apply.)

a.

Environment

b.

Physical status

c.

Financial status

d.

Functional status

e.

Medical history

f.

Occupational history

ANS: A, B, D, E

The nurse uses information about lighting, flooring, apparel, and other issues from the environmental assessment of an older adult to plan individualized fall prevention measures. The nurse examines flexibility, muscle strength, vital signs, and other clinical indicators in the physical assessment of an older adult to plan individualized fall prevention measures. The nurse uses information about gait, balance, and ability to perform activities of daily living in the functional status assessment of an older adult to plan individualized fall prevention measures. The nurse examines medications, previous accidents and falls, co-morbid conditions, and other factors in the historical assessment of an older adult to plan individualized fall prevention measures. Financial issues and occupational history are not directly related to a risk for falls.

PTS:1DIF:RememberREF:200-204

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

4. The nurse is caring for an older adult who has dementia. The patient has just returned from recovery after a percutaneous endoscopic gastrostomy (PEG) tube placement. Which intervention(s) should the nurse implement? (Select all that apply.)

a.

Place IV tubing behind the patient.

b.

Hang the IV bag behind the patients field of vision.

c.

Cover the PEG tube with an abdominal binder.

d.

Use wrist restraints.

ANS: A, B, C

Placing the tube behind the patient, hanging the IV bag behind patients field of vision, and covering PEG tube with an abdominal binder decrease the likelihood of the patient accidently pulling out the lines. Soft mitts should be used instead of hand restraints.

PTS: 1 DIF: Apply REF: 215 TOP: Nursing Process: Planning

MSC: Safe, Effective Care Environment

5. Which factors in the patient care environment should be routinely assessed to decrease the risk of falls? (Select all that apply.)

a.

Outdoor grounds

b.

Appropriate footwear

c.

All four bed rails raised

d.

Grab bars in place

ANS: A, B, D

The outdoor grounds should be checked for uneven areas, such as breaks in the sidewalk and items the patients could trip over. Ensuring that patients have the appropriate footwear in important to decrease the risk for falls. Raised bed rails can be considered a restraint. Grab bars are considered assistive devices and can decrease the risk for falls or injuries.

PTS: 1 DIF: Understand REF: 215 TOP: Nursing Process: Planning

MSC: Safe, Effective Care Environment

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