Skills Test 1: Jacobson's Guide Flashcards
Can the nurse delegate applying and removing the restraints, skin care, and checking for skin breakdown?
Yes
Who must assess the patient’s need for restraint and the patient’s status and must evaluate the patient’s response to restraints?
The nurse responsible for care of the patient
The patient should have restraints removed every ___ hours. Skin should be assessed and the patient should be offered the opportunity to use the ________ and to receive nourishment.
2
bathroom
________ _____ are by far the most common incident reported in hospitals and long-term care facilities.
Patient Falls
External pressure from lying or sitting in one position compresses capillaries and obstructs _____ flow to the skin. Immobile patients confined to a bed should be turned at least every __ hours to protect their skin and relieve pressure.
Blood
2
Passive _ _ _ involves moving the patient’s joints through their _ _ _ when the patient is unable to do so for himself.
ROM
Passive ROM promotes ______ mobility.
joint
Would active ROM be possible for a quadriplegic patient?
No
Does turning a patient every 2 hours promote mobility or prevent contracture?
No
If a patient becomes weak or begins to fall when walking, should the nurse attempt to hold the patient up?
No
What should the nurse do instead of trying to hold a patient who is falling up?
Protect the patient as you guide her to a seated or lying position.
How should the nurse help the falling patient to the floor?
Create a wide base of support, and project forward the hip closest to the patient. Assist the patient to slide down your leg as you call for help. Protect the patient’s head as her body descends.
What are the leading cause of injury among nurses.
How can this be prevented?
Back Injuries
Good body mechanics and teamwork limit the risk of injury.
Plantar flexion, contracture or footdrop is a complication seen in __________ patients.
Bedridden
Pressure ulcers and contractures are complications that can develop in patients who do not maintain_______ _______ _______
Correct Body Alignment
A patient who has been immobile for several days or longer may be weak or dizzy or may develop ___________ ___________
(a drop in blood pressure) when transferred.
orthostatic hypotension
How should the nurse assist a patient to a sitting position if that patient has been immobile for several days?
With patient in supine position, raise the head of the bed 30 degrees; this decreases the amount of work needed by the patient and the nurse to raise the patient to a sitting position. The bed should be in the low position. The patient is turned to face the nurse after the head of the bed is raised 30 degrees.
Always have patient wear ______ or ____________ during transfer; bare feet increase risk for falls.
shoes
non-skid socks
Assisting the patient out of bed to chair. Transfer belt allows nurse to maintain _________ of patient during transfer and reduces risk for falling. Transfer belt provides movement of patient at center of _______. Patients should never be lifted by or under _____. If patient demonstrates weakness or paralysis of one side of the body, place chair on patient’s ______ side. The patient would move forward toward the strong side. Have chair in position at __-degree angle to bed.
stability
gravity
arms
strong
45
Physical stress can be decreased significantly by the use of a slide board or a _______-reducing board positioned under a drawsheet beneath the patient. In addition, the patient is more comfortable using this method._____ patient’s arms on chest to prevent injury to arms during transfer.
Friction
Cross
