Exam 1 - Chapter 27

Question 1

When performing a safety assessment, the nurse focuses on what three categories

Answer 1

The person, the environment, and specific risk factors

Question 2

What does assessing a person consist of

Answer 2

Consists of nursing history and a physical examination

Question 3

What are some common risk factors that nurses should assess?

Answer 3

Falls, Fires, Poisoning, Suffocation and Choking, and Firearm Injuries

Question 4

Falls can be categorized into what categories

Answer 4

Accidental
Anticipated Physiological Fall
Unanticipated Physiologic Fall
Intentional Falls

Question 5

Whats a accidental fall

Answer 5

clutter or a spill caused a person to trip

Question 6

Whats an anticipated physiologic fall

Answer 6

firect consequence of gait imbalances, effects of medication, or dementia

Question 7

whats an unanticipated physiologic fall

Answer 7

caused by unknown or unexpected medical issues such as a stroke or seizure

Question 8

whats an intentional fall

Answer 8

occur when patients act out behaviorally with intent to fall

Question 9

What three questions should health care providers ask with every encounter with older adults?

Answer 9

Have you fallen in the past year?
Do you feel usnteady when standing or walking?
Do you worry about falling?

Question 10

What is Asphyxiation??

Answer 10

Suffocation

Question 11

What is the three step plan that nurses should always follow?

Answer 11

Assess - Diagnose - Implement

Question 12

What should you do during a Physical Examination?

Answer 12

Assess Mobility Sttus
Assess abillity to communicate
Assess levels of awareness
Assess sensory perception
identify potential safety hazards
recognize domestic violence

Question 13

Nursing Intervention for Safety

Answer 13

Identify real and unsafe environments
Implement safety measure
Incorporate accident prevent
Orient patient to surrounding

Question 14

Nursing Interventions for Confused Patient

Answer 14

Always ass level of confusion first

2. Orient to person, place, time
3. try to keep near nurses station
4. allow family to stay
5. try to have same nurse work

Question 15

Patient Education for Home

Answer 15

Fall Prevent
Avoid smoking with oxygen
Avoid unsafe storage of hazardous materials

Question 16

Patient Education for Hospital

Answer 16

Orient to surroundings and equipment

Explain activity restrictions to increase compliance

Question 17

Factorss that contribute to falls

Answer 17

Age > 65
History of Falls
impaired vision or balance
Altered gait
medication regimen
Confusion or disorientation

Question 18

What is a Physical Restraint?

Answer 18

A physical device to limit a patients movements.

Question 19

Whats a chemical restraint?

Answer 19

Drugs used to control a PT behavior that is not part of their routine medication schedole

Question 20

Physiological Hazards Associated with REstraints

Answer 20

Increased possibility of injury
Skin Breakdown
Depression
Anxiety
Aspiration
Death