Chapter 13: Safety and Quality Improvement Nursing School Test Banks

MULTIPLE CHOICE

1. The patient is admitted to the hospital with orders for activity as tolerated. He is wheelchair-bound at home and has brought his own electric wheelchair and battery charger to help him maintain mobility. The nurse realizes that:

a.

patients are not allowed to bring in an electric wheelchair.

b.

electrical equipment is banned from all hospitals.

c.

the charger needs to be checked by hospital engineers.

d.

electrical devices are not a cause for concern.

ANS: C

The third (longer) prong in an electrical plug is the ground. If a patient brings an electrical device to the hospital, an engineer inspects the device for safe wiring and function before use. Many patients with disabilities use battery chargers for mobility equipment function. These devices need to be inspected by hospital engineers. Fires in health care settings typically are electrical or anesthetic-related.

DIF: Cognitive Level: Comprehension REF: Text reference: p. 313

OBJ: Describe methods used to evaluate interventions designed to maintain or promote a patients safety. TOP: Fire/Electrical Safety

KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity

2. Upon entering the patients room, the nurse sees a fire burning in the trash can next to the bed. The nurse removes the patient and reports the fire. What is the nurses next action?

a.

Extinguish the fire.

b.

Remove all other patients from the unit.

c.

Close all doors of patient rooms.

d.

Move the trash can into the bathroom.

ANS: C

Using the RACE acronym, the next action the nurse should take is to confine the fire by closing doors and windows and turning off oxygen and electrical equipment (Rescue, Activate, Contain, and Evacuate). Extinguish the fire by using an extinguisher after ensuring patient and individual safety after closing the doors of patient rooms. After activating the alarm, the nurse should close all the doors, not remove all the other patients from the unit. Moving the trash can would not be an appropriate action, as the nurse could get burned in this attempt.

DIF: Cognitive Level: Application REF: Text reference: p. 313

OBJ: Describe nursing interventions taken in the event of fire and electrical shock.

TOP: Fire Safety KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity

3. In a long-term care facility, an elderly patient drops his burning cigarette into a trash can and starts a fire. A Type _____ fire extinguisher is the most appropriate type of fire extinguisher for the nurse to use in this situation.

a.

A

b.

B

c.

C

d.

D

ANS: A

Type A fire extinguishers are used for ordinary combustibles such as wood, cloth, paper, and plastic. A trash can fire would require a type A fire extinguisher. Type B fire extinguishers are used for flammable liquids such as gasoline, grease, paint, and anesthetic gas. Type C fire extinguishers are used for electrical fires. There is no Type D fire extinguisher.

DIF: Cognitive Level: Comprehension REF: Text reference: p. 314

OBJ: Describe nursing interventions performed in the event of fire and electrical shock.

TOP: Fire Extinguishers KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity

4. Given the most common causes of hospital fires, which of the following choices are most appropriate in preventing patient injury?

a.

Assure that all electrical devices are checked by engineering.

b.

Assist patients who smoke to a safe area to smoke.

c.

Prop fire doors open for easier patient access.

d.

Educate patients on the importance of smoking cessation.

ANS: A

Fires in health care settings are usually electrical or anesthetic-related, so ensuring all electrical devices are inspected will greatly reduce the risk of fire. Look for inspection labels verifying recent inspection for all electrical devices. Fire door should never be propped open. While educating patients on smoking cessation is a good idea, it will have little impact on immediate hospital safety. Although smoking is no longer allowed in the hospital setting, smoking-related fires continue to pose a risk due to unauthorized smoking in bed or the bathroom.

DIF: Cognitive Level: Analysis REF: Text reference: p. 312

OBJ: Describe nursing interventions performed in the event of fire and electrical shock.

TOP: Fire Extinguishers KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity

5. After recognizing that a patient has received an electrical shock and removing the source of the shock, what should the nurse do next?

a.

Call for assistance.

b.

Immediately start CPR.

c.

Obtain emergency equipment.

d.

Assess for the presence of a pulse.

ANS: D

If the patient receives an electrical shock, immediately assess for the presence of a pulse. Electrical shock can cause cardiac arrest, asystole. Do not leave the patient. Only if the patient is pulseless will the nurse institute cardiopulmonary resuscitation. If the patient has a pulse and remains alert and oriented, obtain vital signs and assess the skin for signs of thermal injury. Electrical current will cause burn at points of entry and exit from the body.

DIF: Cognitive Level: Application REF: Text reference: p. 314

OBJ: Describe nursing interventions performed in the event of fire and electrical shock.

TOP: Electrical Shock KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity

6. The patient is an elderly gentleman who is admitted for a medical problem. While doing his admission assessment, the nurse learns that the patient gets up two to three times a night to use the restroom. The institution has only beds with four side rails. Which of the following is the appropriate rationale for leaving one of the lower side rails down?

a.

Falls rarely happen in the inpatient setting.

b.

Having all side rails raised increases the occurrence of falling.

c.

Side rails have no bearing on whether or not a patient falls.

d.

Patient falls rarely result in physical injury.

ANS: B

Having all four side rails raised often increases the occurrence of falling, because patients try to climb over the rails to reach a chair or bathroom and often fall farther as a result. Leaving three side rails up (two upper and one lower) on a bed with four side rails is safer for the patient. Leaving the lower side rail down on the side of the bed the patient will exit the bed from to access the bathroom reduces the risk of falls.

DIF: Cognitive Level: Comprehension REF: Text reference: p. 297

OBJ: Discuss the importance of a nursing assessment in providing for patient safety.

TOP: Falls Prevention KEY: Nursing Process Step: Planning

MSC: NCLEX: Physiological Integrity

7. A patient is taking a medication that has the potential to cause orthostatic hypotension. Which of the following nursing interventions is appropriate for this patient?

a.

Have the patient sit slowly and dangle.

b.

Refer the patient to physical therapy.

c.

Keep the side rails up at all times.

d.

Obtain a walker or a cane for patient use.

ANS: A

Dangling allows adjustment to orthostatic hypotension, permitting blood pressure to stabilize before ambulating. Have the patient dangle his or her feet for a few minutes before standing, walk slowly, and ask for help if dizzy or weak. The nurse would confer with physical therapy on the feasibility of gait training and muscle-strengthening exercise. Check agency policies regarding side rail use. Side rails are a restraint device if they immobilize or reduce the ability of a patient to move his or her arms, legs, body, or head freely. Keep one side rail up in a two-rail system, and keep three of four rails up (one lower rail down) in a four-rail system, with the bed in low position and wheels locked, when you are not administering patient care. This allows the patient to maneuver and get out of bed safely. Do not assume that the patient requires a walker or a cane. Evaluate the need for assistive devices such as walker, cane, or bedside commode. Assistive devices may provide greater stability and may help the patient to assume a more active role.

DIF: Cognitive Level: Application REF: Text reference: p. 301

OBJ: Describe nursing interventions specific for reducing the risk for falls.

TOP: Orthostatic Hypotension KEY: Nursing Process Step: Assessment

MSC: NCLEX: Physiological Integrity

8. What should the nurse do to promote patient understanding and security in the health care setting?

a.

Restrain the patient as necessary.

b.

Explain all procedures to the patient.

c.

Allow the patient more time alone.

d.

Restrict activity as much as possible.

ANS: B

Orient patient and family to surroundings, introduce to staff, and explain all treatments and procedures. This promotes patient understanding and cooperation. The use of restraints is one safety strategy that can protect patients from injury, but restraints must be used with extreme caution. Physical restraints should be the last resort and should be used only when reasonable alternatives have failed. Isolation may increase anxiety. Encourage family and friends to stay with the patient. Sitters or companions may be used. In some institutions, volunteers can be effective companions. Patient anxiety is reduced and safety is increased when one person provides care and supervision is constant. Constant activity may irritate the patient, yet the lack of activity may create anxiety and/or boredom. Meaningful diversional activities provide distraction, help to reduce boredom, and provide tactile stimulation. Minimize occurrences of wandering.

DIF: Cognitive Level: Comprehension REF: Text reference: p. 299

OBJ: Describe steps in the design of a restraint-free environment.

TOP: Alternatives to Physical Restraint KEY: Nursing Process Step: Planning

MSC: NCLEX: Physiological Integrity

9. As part of an attempt to implement a restraint-free environment, the nurse:

a.

provides constant activity for the patient.

b.

covers or camouflages tubes and drains.

c.

changes caregivers as often as possible.

d.

reduces visiting hours and times in therapy.

ANS: B

Position intravenous (IV) catheters, urinary catheters, and tubes/drains out of patient view, or use camouflage by wrapping the IV site with bandage or stockinette, placing undergarments on patients with a urinary catheter, or covering abdominal feeding tubes/drains with a loose abdominal binder. This helps maintain medical treatment and reduces patient access to tubes/lines. Provide scheduled ambulation, chair activity, and toileting. Organize treatments so the patient has long uninterrupted periods throughout the day. Provide for sleep and rest periods. Constant activity may irritate the patient. Provide the same caregivers to the extent possible. This increases familiarity with individuals in the patients environment, decreasing anxiety and restlessness. Encourage family and friends to stay with the patient. Sitters or companions may be used. In some institutions, volunteers can be effective companions. Patient anxiety is reduced and safety is increased when one person provides care and supervision is constant.

DIF: Cognitive Level: Application REF: Text reference: p. 305

OBJ: Describe steps in the design of a restraint-free environment.

TOP: Alternatives to Physical Restraint KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity

10. A patient is well known to the hospital staff from previous admissions and is prone to wandering at night. For patient safety, the physician writes an order for belt restraint prn. What should the nurse do upon reviewing this order?

a.

Apply a belt restraint on the patient as needed.

b.

Have the patient sign an informed consent form.

c.

Inform the physician that prn restraint orders are unacceptable.

d.

Obtain a signed informed consent from a family member.

ANS: C

The use of mechanical or physical restraints should be part of a patients prescribed medical treatment. A physicians time-limited order is necessary. The patients or family members informed consent is necessary in the long-term care setting.

DIF: Cognitive Level: Application REF: Text reference: p. 308

OBJ: Discuss precautions used to prevent injury in patients who are restrained.

TOP: Applying Physical Restraints KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity

11. To promote patient safety, government standards regarding mechanical and physical restraints state that:

a.

alternative measures are to be implemented before restraints are used.

b.

the nurses judgment is all that is required for restraint use.

c.

restraints should be used immediately for all patients who may need them.

d.

restraints cannot be used except to prevent others from being harmed.

ANS: A

The use of mechanical or physical restraints must be part of the prescribed medical treatment, all less-restrictive interventions must be tried first, other disciplines must be applied, and supporting documentation must be provided. If the alternatives fail, the nurse may consider use of a restraint to prevent injury. Determine the patients need for restraint if other less-restrictive measures fail to prevent interruption of therapy or injury to self or others. Confer with the physician or primary health care provider, who must write the order for restraints. Restraints may be needed for the confused or combative patient to prevent interruption of therapy or injury to self or others. Confer with the physician or primary health care provider.

DIF: Cognitive Level: Application REF: Text reference: p. 308|Text reference: p. 312

OBJ: Discuss precautions used to prevent injury in patients who are restrained.

TOP: Applying Physical Restraints KEY: Nursing Process Step: Planning

MSC: NCLEX: Physiological Integrity

12. When applying a belt restraint to a patient, it is important for the nurse to:

a.

apply the belt under the hospital gown.

b.

place the restraint around the abdomen.

c.

have the patient in a sitting position.

d.

apply the belt as tightly as possible.

ANS: C

Have the patient in a sitting position. Remove wrinkles or creases in clothing. Bring ties through slots in a belt. Apply a belt over clothes, gown, or pajamas to prevent damage to the skin. Make sure to place the restraint at the waist, not at the chest or abdomen. Avoid applying the belt too tightly.

DIF: Cognitive Level: Application REF: Text reference: p. 309

OBJ: Discuss precautions used to prevent injury in patients who are restrained.

TOP: Belt Restraints KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity

13. When caring for a patient who has been restrained, how often will the nurse perform an assessment?

a.

Every 15 minutes

b.

Every 30 minutes

c.

Every hour

d.

Every 2 hours

ANS: A

After application, evaluate the patients condition every 15 minutes for signs of injury. Frequent assessments prevent injury to the patient and allow removal of the restraint at the earliest possible time. Observation and frequent assessments prevent complications such as suffocation, skin breakdown, and impaired circulation. The Joint Commission recommends that the patients condition be evaluated every 15 minutes. If the nurse restrains the patient in an emergency situation because of violent or aggressive behavior that presents an immediate danger, a face-to-face physician assessment within 1 hour is needed to determine the patients continued need for restraints. Restraints should be removed at least every 2 hours. If the patient is violent or noncompliant, remove one restraint at a time and/or have staff assistance while removing restraints. Removal provides an opportunity to change the patients position, offer nutrients, perform full range of joint motion (ROJM), and toilet and exercise the patient.

DIF: Cognitive Level: Comprehension REF: Text reference: p. 311

OBJ: Discuss precautions used to prevent injury in patients who are restrained.

TOP: Evaluation of Patient Condition KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity

14. When caring for a patient who has an arm or leg restraint in place, how often will the nurse remove the restraint?

a.

Every 15 minutes

b.

Every 30 minutes

c.

Every hour

d.

Every 2 hours

ANS: D

Restraints should be removed at least every 2 hours (Joint Commission on Accreditation of Healthcare Organizations [JCAHO], 2004). If the patient is violent or noncompliant, remove one restraint at a time and/or have staff assistance while removing restraints. Removal provides an opportunity to change the patients position, offer nutrients, perform full ROJM, and toilet and exercise the patient. After application, evaluate the patients condition for signs of injury every 15 minutes. Frequent assessments prevent injury to the patient and allow removal of the restraint at the earliest possible time. If the patient shows no sign of impaired circulation or other complications, the restraint does not need to be removed at this time. If the nurse restrains a patient in an emergency situation because of violent or aggressive behavior, this presents an immediate danger; a face-to-face physician assessment is needed within 1 hour to determine the patients need for the restraint.

DIF: Cognitive Level: Comprehension REF: Text reference: pp. 311-312

OBJ: Discuss precautions used to prevent injury in patients who are restrained.

TOP: Evaluation of Patient Condition KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity

15. When assessing a patient, a nurse notes that the skin distal to a restraint is pale and cool to the touch. Which of the following interventions will the nurse perform first?

a.

Remove the restraint.

b.

Loosen the restraint.

c.

Obtain a larger restraint.

d.

Reapply the restraint with more padding.

ANS: A

If a patient has altered neurovascular status of an extremity, such as cyanosis, pallor and coldness of skin, or complaints of tingling, pain, or numbness, remove the restraint immediately, and notify the physician. Loosening the restraint may not effectively restore adequate circulation. An improperly sized restraint may not provide the protection needed for the patient.

DIF: Cognitive Level: Application REF: Text reference: p. 312

OBJ: Discuss precautions used to prevent injury in patients who are restrained.

TOP: Altered Neurovascular Status of an Extremity

KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity

16. A nurse enters the room of a patient who is sitting in a chair and begins to have a seizure. To promote patient safety, which nursing intervention will the nurse initially perform?

a.

Immediately call for assistance.

b.

Assist the patient to the floor.

c.

Put the patient back into the bed.

d.

Insert a padded tongue blade into the patients mouth.

ANS: B

When the seizure begins, position the patient safely. If the patient is standing or sitting, guide the patient to the floor and protect the head by cradling in the nurses lap or placing a pillow under the head. Clear the surrounding area of furniture. If the patient is in bed, raise the side rails and pad, and put the bed in a low position. Stay with the patient, and observe the sequence and timing of seizure activity. Continued observation ensures adequate ventilation during and after a seizure and will assist in documentation, diagnosis, and treatment of a seizure disorder. If possible, turn the patient onto one side, with the head tilted slightly forward. This allows the tongue to fall away from the airway, permitting drainage of saliva and vomitus, and prevents aspiration. Do not force any objects such as fingers, medicine or tongue depressor, or airway into the patients mouth when the teeth are clenched. This could cause injury to the mouth and stimulate gagging, which could lead to aspiration.

DIF: Cognitive Level: Application REF: Text reference: p. 316

OBJ: Describe nursing interventions for a patient who experiences generalized seizures.

TOP: Seizures KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity

17. What should the nurse do to prevent a patient from aspirating during a seizure?

a.

Insert an oral airway.

b.

Restrain the patient securely.

c.

Sit the patient upright.

d.

Turn the patient onto his/her side.

ANS: D

If possible, turn the patient onto the side, with the head flexed slightly forward. This position prevents the tongue from blocking the airway and promotes drainage of secretions, thus reducing the risk for aspiration. Do not force any objects such as fingers, medicine or tongue depressor, or airway into the patients mouth when the teeth are clenched. This could cause injury to the mouth and could stimulate gagging, leading to possible aspiration. Do not restrain the patient. Loosen clothing to prevent musculoskeletal injury and airway obstruction. When a seizure begins, position the patient safely. If the patient is standing or sitting, guide the patient to the floor and protect the head by cradling in the nurses lap or placing a pillow under the head. Clear the surrounding area of furniture. If the patient is in bed, raise the side rails and pad, and put the bed in a low position.

DIF: Cognitive Level: Application REF: Text reference: p. 316

OBJ: Describe nursing interventions for a patient who experiences generalized seizures.

TOP: Aspiration KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity

MULTIPLE RESPONSE

1. A safe health care environment is one in which: (Select all that apply.)

a.

the patients basic needs are met.

b.

physical hazards are reduced.

c.

transmission of microorganisms is reduced.

d.

sanitary measures are carried out.

ANS: A, B, C, D

A safe environment is one in which the patients basic needs are met, physical hazards are reduced or eliminated, transmission of microorganisms is reduced, and sanitary measures are carried out.

DIF: Cognitive Level: Comprehension REF: Text reference: pp. 295-296

OBJ: Describe methods used to evaluate interventions designed to maintain or promote a patients safety. TOP: Safe Environment KEY: Nursing Process Step: Assessment

MSC: NCLEX: Physiological Integrity

2. Effective fall prevention programs include which of the following? (Select all that apply.)

a.

Risk assessment

b.

Medication reviews

c.

Use of assistive devices

d.

Exercise and strength training

ANS: A, B, C, D

Evidence shows that hospital-based fall prevention programs that focus on a multifactorial approach reduce fall rates (CDC, 2006). Effective fall prevention programs include risk assessment, medication reviews with necessary modifications, use of assistive devices, exercise and strength training, and education for home safety.

DIF: Cognitive Level: Comprehension REF: Text reference: pp. 296-297

OBJ: Discuss current evidence in the area of fall prevention. TOP: Fall Prevention Programs

KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity

3. Which of the following fall prevention strategies should the nurse perform on all hospitalized patients? (Select all that apply.)

a.

Conduct hourly rounds.

b.

Provide the patient regular toileting.

c.

Assess the patients comfort needs.

d.

Evaluate the effectiveness of pain medication.

ANS: A, B, C

A recent study shows that hourly nurse rounds are an effective strategy for reducing falls. Combining hourly rounds with activities such as regular toileting and assessing the patients comfort needs manages those factors that often prompt patients to get out of bed without assistance. In the hospital setting, a variety of fall risk factor screening tools are available. Because multiple risk factors for falls are known, no single assessment tool is sensitive and specific for analyzing fall risk.

DIF: Cognitive Level: Comprehension REF: Text reference: p. 302|Text reference: p. 305

OBJ: Describe nursing interventions specific for reducing the risk for falls.

TOP: Fall Prevention Programs KEY: Nursing Process Step: Assessment

MSC: NCLEX: Physiological Integrity

4. Which of the following alternatives to physical restraints should the nurse use to promote patient safety? (Select all that apply.)

a.

Environmental modifications

b.

Less frequent patient observation

c.

Involvement of family during visitation

d.

Frequent reorientation of the patient

ANS: A, C, D

Many alternatives to the use of restraints are available, and you should try all of them before using restraints. Modification of the environment is an effective alternative to restraints. More frequent observation of patients, involvement of family during visitation, and frequent reorientation are helpful measures.

DIF: Cognitive Level: Application REF: Text reference: p. 304

OBJ: Describe steps in the design of a restraint-free environment.

TOP: Alternatives to Physical Restraint KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity

5. The use of restraints has been associated with which of the following complications? (Select all that apply.)

a.

Pressure ulcers

b.

Pneumonia

c.

Constipation

d.

Death

ANS: A, B, C, D

The use of restraints is associated with several serious complications, including pressure ulcers, hypostatic pneumonia, constipation, incontinence, and death.

DIF: Cognitive Level: Comprehension REF: Text reference: p. 308

OBJ: Discuss precautions used to prevent injury in patients who are restrained.

TOP: Applying Physical Restraints KEY: Nursing Process Step: Assessment

MSC: NCLEX: Physiological Integrity

6. When working with a patient who has a new seizure disorder, the nurse is alerted to the need for further instruction when the patient tells the nurse: (Select all that apply.)

a.

I will avoid over-the-counter medications that contain alcohol.

b.

I have the medications that I take listed on this card that I carry with me.

c.

I will be sure to take my medications as prescribed by my provider.

d.

I will visit my physician right after I return home from my next trucking job.

ANS: B, D

Patients should wear a medical alert bracelet or carry an identification card noting the presence of seizure disorder and listing medications taken. Without a medical alert bracelet or identification noting the presence of seizure disorder and medications taken, just having the medications at work or home will not necessarily mean that the appropriate treatment will be started. A seizure condition usually imposes driving limitations. It is recommended that a waiting period of 1 seizure-free year elapses before the patient attempts to drive or operate dangerous equipment.

DIF: Cognitive Level: Application REF: Text reference: p. 318

OBJ: Describe nursing interventions for a patient who experiences generalized seizures.

TOP: Teaching Considerations KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity

COMPLETION

1. It is important for nurses to understand what patients perceive as ___________ so that patients will become partners in programs to prevent them.

ANS:

errors

mistakes

problems

Patients consider falls, communication problems, and lack of nurse responsiveness as errors, along with medication errors and injury from medical equipment. It is important for nurses to understand what patients perceive as errors, so that patients will become partners in programs to prevent errors.

DIF: Cognitive Level: Comprehension REF: Text reference: p. 296

OBJ: Describe methods used to evaluate interventions designed to maintain or promote a patients safety. TOP: Medical Errors KEY: Nursing Process Step: Assessment

MSC: NCLEX: Physiological Integrity

2. More than ____________ patients are injured in falls in inpatient settings annually in the United States.

ANS:

one million

1 million

Patient falls are the most common type of inpatient accidents in the United States. TJC recommends that all hospitals develop a fall prevention program and evaluate its effectiveness regularly.

DIF: Cognitive Level: Knowledge REF: Text reference: p. 297

OBJ: Describe methods used to evaluate interventions designed to maintain or promote a patients safety. TOP: Medical Errors KEY: Nursing Process Step: Assessment

MSC: NCLEX: Physiological Integrity

3. Health care facilities must provide employees access to information about the properties of particular chemicals and information for handling substances in a safe manner. Facilities do this by providing ______________.

ANS:

material safety data sheets (MSDSs)

Health care facilities provide employees access to a material safety data sheet (MSDS) for each hazardous chemical. An MSDS is a form that contains data about the properties of a particular chemical and information for handling a substance in a safe manner (e.g., storage, disposal, protective equipment, spill handling procedures).

DIF: Cognitive Level: Comprehension REF: Text reference: p. 313

OBJ: Describe methods used to evaluate interventions designed to maintain or promote a patients safety. TOP: Material Safety Data Sheets (MSDS)

KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity

4. __________ are the most common type of inpatient accident.

ANS:

Falls

Falls are the most common type of inpatient accident. Approximately 30% of hospital patient falls result in physical injury.

DIF: Cognitive Level: Comprehension REF: Text reference: p. 297

OBJ: Discuss current evidence in the area of fall prevention. TOP: Falls

KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity

5. The use of physical restraints is one safety strategy that has been used to protect patients from injury. However, physical restraints should be used as a ______________ and are used only when reasonable alternatives have failed.

ANS:

last resort

The use of physical restraints is one safety strategy that has been used to protect patients from injury. However, efforts have been in place for several years by the Centers for Medicare and Medicaid Services and The Joint Commission to reduce the use of restraints and to use them only under extreme caution. Physical restraints are the last resort and are used only when reasonable alternatives have failed.

DIF: Cognitive Level: Application REF: Text reference: p. 307

OBJ: Describe steps in the design of a restraint-free environment.

TOP: Physical Restraint KEY: Nursing Process Step: Assessment

MSC: NCLEX: Physiological Integrity

6. An ________________ maintains immobilization of the extremities to protect the patient from accidental removal of a therapeutic device.

ANS: extremity restraint

DIF: Cognitive Level: Comprehension REF: Text reference: p. 309

OBJ: Discuss precautions used to prevent injury in patients who are restrained.

TOP: Extremity Restraints KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity

7. A thumb-less device used to restrain patients hands to prevent them from dislodging invasive equipment, removing dressings, or scratching is known as a _____________.

ANS:

mitten restraint

A mitten restraint is a thumb-less mitten device that restrains patients hands and prevents patients from dislodging invasive equipment, removing dressings, or scratching, yet it allows greater movement than is permitted with a wrist restraint.

DIF: Cognitive Level: Comprehension REF: Text reference: p. 309

OBJ: Discuss precautions used to prevent injury in patients who are restrained.

TOP: Mitten Restraints KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity

8. _________________ are sudden, abnormal, and excessive electrical discharges from the brain that change motor or autonomic function, consciousness, or sensation.

ANS:

Seizures

Seizures are sudden, abnormal, and excessive electrical discharges from the brain that change motor or autonomic function, consciousness, or sensation.

DIF: Cognitive Level: Knowledge REF: Text reference: p. 315

OBJ: Describe nursing interventions for a patient who experiences generalized seizures.

TOP: Seizures KEY: Nursing Process Step: Assessment

MSC: NCLEX: Physiological Integrity

9. Continuous seizure activity that lasts longer than 10 minutes is known as _______________.

ANS:

status epilepticus

Continuous seizure activity that lasts longer than 10 minutes is status epilepticus, which is a medical emergency.

DIF: Cognitive Level: Knowledge REF: Text reference: p. 315

OBJ: Describe nursing interventions for a patient who experiences generalized seizures.

TOP: Status Epilepticus KEY: Nursing Process Step: Assessment

MSC: NCLEX: Physiological Integrity

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