Sherpath wk 4 – Flashcards
Unlock all answers in this set
Unlock answersquestion
John Hopkins Fall Assessment Tool
answer
Seven-item assessment tool used in hospitals, completed at bedside, determine low, moderate, or high risk, fall risk factor category 1 and 2, information about pt's meds and eliminations
question
Hendrich II Fall Risk Model
answer
Eight-item assessment tool used in acute care settings; focuses on confusion, symptomatic depression, altered elimination, dizziness, male, antiepileptics, benzodiazepines, get up and go test' points are weighted, 5 or higher high risk
question
Morse Fall Scale
answer
Six-item assessment tool used in acute care and long term care settings, items looked at are fall history (yes/no), existence of secondary diagnosis, use of ambulatory aids, IV line or Saline Lock, Gait, mental status, scores are weighted; high risk 45+, mod 25-44, and low 0-24
question
A patient has been admitted after falling at home and breaking an arm. When asked about the trip and fall hazards in the home, the patient states the home has hardwood flooring and area rugs in the main rooms. What additional question should the nurse ask to ensure the flooring is safe?
answer
Do the area rugs have rug pads underneath them? Meaning: non-slip rug pads
question
John Hopkins Category 1
answer
condition that would automatically assign patient to low or high risk, Factors include: complete immobilization (low risk), history of falls in last 6 months (high risk), deemed high risk per protocol (seizure precautions (high risk))
question
John Hopkins Category 2
answer
Evaluates patient plus 7 factors that contribute to fall; Age, Fall history (1 in last 6 months or never), Elimination concerns, Medications, care equipment that tethers, mobility, cognition; points applied, score assigns level of risk
question
Which is the priority nursing diagnosis related to safety when planning care for a pediatric patient with burns on over 50 percent of the body?
answer
Risk for infection
question
A postpartum mother will require education regarding newborn care prior to discharge. The priority nursing diagnosis for this mother is Knowledge Deficit. What kind of support should the nurse include in the plan of care related to newborn injury prevention and safety promotion?
answer
Bathing techniques, Handling a crying baby, Sleeping practices
question
A nurse working at a rehabilitation center has a patient who is paralyzed from the waist down. The patient needs assistance with mobility, bathing, and other activities of daily living (ADLs). Which helpful resources related to safety and injury prevention will the nurse coordinate?
answer
Obtaining a health aide when family members not available, and Ordering assistive devices
question
The nurse is providing care to a child who is the victim of physical abuse. When planning collaborative care for this patient to enhance safety, which providers should the nurse include?
answer
Psychologist, and Social Worker
question
The nurse is providing care to a newborn whose sibling passed away during infancy due to unknown causes. Which nursing diagnosis related to the newborn's safety should the nurse include in the plan of care?
answer
Risk for SIDS
question
Which goals are appropriate for the nurse to include in the plan of care for a patient who suffered a hip fracture, and subsequent total hip replacement, related to injury prevention and safety promotion?
answer
Patient will experience no injury during the remainder of hospital stay, Patient will consent to having grab bars installed in home bathroom, and Patient will consent to have safety hazards removed from home
question
The nurse is planning care for an adult heart transplant patient who is about to be discharged from the hospital. Which essential members of the collaborative health care team should the nurse include in the discharge planning conference to minimize safety issues for this patient?
answer
Patient and family, transplant care coordinator, pharmacist who has helped adjust medication doses, and Primary health care provider who will continue to provide care
question
Which action(s) exhibited by the nurse displays an appropriate understanding of protective isolation?
answer
placed AIDS patient in private room, demonstrates strict hand washing when dealing with a patient undergoing chemo, changes nurse gown upon each entrance to a neutropenic patient room
question
Which action best displays the nurse's understanding of proper surgical asepsis?
answer
inserting a urinary catheter; used for specialized surgical procedures and invasive procedures such as catheterization
question
Besides quarantine and isolation, which other strategies are used to contain the spread of illness?
answer
Early detection, rapid diagnosis, and treatment with antibiotics and antivirals
question
Mrs. White has a left leg infection. She enjoys that her husband visits with her every day and evening. She can be indecisive about taking her medication, at times refusing it all together. What is a possible strategy the nurse could use to revise her goals and encourage more effective care?
answer
Collaborate with the husband
question
Which are the first two steps in creating collaborative, patient-centered care?
answer
Evaluate, and Prioritize
question
A surgical incision would immediately qualify which nursing diagnosis?
answer
Impaired skin integrity
question
Which are measureable and can be applied to goals related to infection?
answer
Hand washing, teeth brushing, Pain, and Loss of appetite
question
Why is mental status an important, measurable item to include in objective data to assist in selection of a nursing diagnosis?
answer
Show if an infection is present and it can show if a patient can process any teaching
question
The nurse is concerned about the fire hazards associated with home oxygen therapy for a patient being discharged to home with oxygen. What education should be included when teaching this patient?
answer
Do not start a fire in the fireplace in the home; patients should not have open flames or smoke in the home with oxygen therapy
question
A student nurse is participating in fire safety drills at the hospital. Which action made by the nurse indicates a need for further teaching?
answer
The nurse transports ambulatory patients to a safe area via bed or stretcher; ambulatory patients should ambulate on their own, not by bed or stretcher
question
Which of these are examples of localized infections?
answer
large pimple, swollen, red cuticle, pressure ulcer
question
The nurse is caring for a patient at risk for developing an infection and when taking vital signs, notices a severe drop in blood pressure. What does the nurse suspect?
answer
septicemia and shock; decrease in BP in a patient at risk for a systemic infection is an indication of this
question
Which of these are older adults at an increased risk of developing?
answer
UTI, Respiratory infections and skin infections
question
Which factors increase the risk of an individual catching an infection?
answer
Morphology, disability, and Gender
question
A nurse is caring for a patient at an increased risk for a systemic infection. Which blood test would indicate that inflammation is present?
answer
Erythrocyte sedimentation rate (ESR); shows inflammation occurring and measures degree of inflammation in the body
question
While caring for a patient at high risk for developing an infection, the nurse observes that the patient's ESR remains elevated for the past three days. What can the nurse consider based on these results?
answer
patient is responding poorly to therapy, and patient is experiencing inflammation and may have infection
question
Which are strategies of collecting key patient assessment data?
answer
performing a general assessment, assessing the patient's vital signs, and obtaining a thorough history
question
Which vital signs when altered may indicate an infection?
answer
Elevated temperature, increased pulse and RR, and elevated BP
