Deck 7: Safe Client Environment and Restraints

Question 1

List 4 assessments that are completed when reviewing potential risk factors that lead to the development of falls in the elderly client.
a.
b.
c.
d.

Answer 1

Review history and circumstances of falls.
Assess home for hazards.
Identify medications routinely taken.
Assess gait,balance,mobility,and muscle weakness.
Assess visual impairment and effects of corrective eyewear.
Assess for urinary incontinence.
Assess acute and chronic heath problems.

Question 2

You are discussing fall prevention for elderly clients with a class of newly hired staff nurses.Identify four factors you will discuss in the class.
a.
b.
c.
d.

Answer 2

Utilize exercise programs,behavior changes,medication review and modification,treatment of contributing health conditions,use of assistive and protective devices,modify house to prevent injury,educate client and family in ways to prevent falls.

Question 3

Which of the following physical restraints does not require a physician's order or signed approval?

A)Arm board for IV stabilizations
B)Humane belt to remind client to call for assistance
C)Soft wrist restraints to prevent client from removing dressing
D)Hand mitts to prevent client from pulling Foley catheter

Answer 3

Arm board for IV stabilizations

Question 4

Which of the following is an appropriate nursing action for preventing mechanical injuries?

A)Listen to client's complaints.
B)Always keep bed in low position.
C)Make sure floors are free of debris.
D)Use restraints.

Question 5

A client's visitor falls in the hallway.Your initial action is to do which one of the following?

A)Notify the client's physician.
B)Fill out an unusual occurrence report.
C)Provide first-aid care.
D)Send the visitor to his or her own physician.

Question 6

The need for continuation or termination of restraint use should be determined

A)Weekly.
B)Daily.
C)q8h.
D)By physician order.

Question 7

The most restrictive form of restraint is

A)Humane belt.
B)Torso vest.
C)Wrist restraints.
D)Chemical.

Question 8

Define the word "adaptation."

Question 9

Alternative interventions for the client who pulls at IV lines and catheters include

A)Humane belt.
B)Wrist restraints.
C)Camouflage of lines.
D)Soft wrist restraints.

Question 10

The first sign of possible thermal injury for a client using a heating pad or hot compress is

A)Tingling sensation in the extremities.
B)Redness in the area.
C)Edema.
D)Pain.

Question 11

Which of the following nursing actions is inappropriate for a client using wrist restraints?

A)Check limbs every 2 hours for circulation.
B)Change client's position every 2 hours.
C)Release restraints every shift.
D)Put extremities through range of motion every 2 hours.

Question 12

Define "physical restraint."

Question 13

Which one of the following statements is true regarding wrist restraints?

A)Restraints should be used on all elderly clients.
B)Physician's orders are not required for soft restraints.
C)When bony prominences are padded,circulatory impairment does not occur.
D)Allow as much freedom as possible when restraints are applied.

Question 14

The sociocultural dimensions of an environment include which one of the following?

A)Individualized client care.
B)Fresh,healthful food.
C)Adequate light.
D)Adequate space.

Question 15

The first step in providing client safety during a fire is to

A)Pull the fire alarm.
B)Turn off the oxygen source.
C)Call the fire department.
D)Remove the client from the area.

Question 16

Proper use of restraints significantly reduces falls in hospitalized clients.

Question 17

The most therapeutic humidity in a client's room should be

A)10-30%
B)30-60%
C)60-70%
D)70-80%

Question 18

Clients are most comfortable if their room is maintained within which one of the following temperature ranges?

A)62°-68°F
B)68°-70°F
C)65°-77°F
D)70°-80°F