Deck 13: Promoting Safety

Question 1

Which of the following is(are)assessed in a fall prevention assessment of an older adult?

A) Environment
B) Physical status
C) Financial status
D) Functional status
E) Medical history
F)Occupational history

Answer 1

Environment
Physical status
Functional status
Medical history

Question 2

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 patient's condition at home?

A) Complaints of shivering
B) Temperature of household
C) Types of food preparation
D) Presence of radon

Answer 2

Temperature of household

Question 3

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.

Answer 3

She takes the walker to the elevator.

Question 4

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

Question 5

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 children's playtime

Question 6

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?

A) Place IV tubing behind the patient.
B) Hang the IV bag behind the patient's field of vision.
C) Cover the PEG tube with an abdominal binder.
D) Use wrist restraints.

Question 7

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

A) Wide rear-view mirrors
B) Pedal extensions
C) Global positioning system (GPS) devices
D) Antiroll bars

Question 8

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 nurse's perception of temperature is a useful guide for patient thermal needs.

Question 9

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.

Question 10

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.

Question 11

Which factors in the patient care environment should be routinely assessed to decrease the risk of falls?

A) Outdoor grounds
B) Appropriate footwear
C) All four bed rails raised
D) Grab bars in place

Question 12

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.

Question 13

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.

Question 14

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?

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

Question 15

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.

Question 16

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 patient's energy and initiative.
D) Lowering the bed and fluorescent tapes are interventions to increase safety.

Question 17

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.

Question 18

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