Solutions - Chapter 32 - Kozier Erb's Fundamentals Nursing - 10 Ed

 

10TYK. The nurse, at change-of-shift report, learns that one of the clients in his care has bilateral soft wrist restraints. The client is confused, is trying to get out of bed, and had pulled out the IV line, which was subsequently reinserted. Which action(s) by the nurse is appropriate? Select all that apply.
1.  Document the behavior(s) that require continued use of the restraints.
2.  Ensure that the restraints are tied to the side rails.
3.  Provide range-of-motion exercises when the restraints are removed.
4.  Orient the client.
Assess the tightness of the restraints.
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1CTC. Mr. Moore is a 72-year-old widower who is recovering from a fall in which he fractured his hip and underwent surgical repair 1 week ago. He will be staying with his son for 2 weeks after he is discharged from the hospital, but he is eager to return to his own home. Once he is home, his son will visit nightly after work, he will receive Meals- on-Wheels once a day, and a home health care attendant will visit weekly to assist him with hygienic care until he is more independent. Mr. Moore’s wife died 3 years ago, but he has remained independent and continued his social functions. He lives in a small single-level house with hts dog and cat, and he enjoys gardening. Prior to fracturing his hip he walked his dog daily. You will be his home health care nurse.
While hospitalized, Mr. Moore experienced some mild confusion during the night, but his nurses decided not to restrain him. What are the best reasons for avoiding the use of restraints for clients such as Mr. Moore?
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2CTC. Mr. Moore is a 72-year-old widower who is recovering from a fall in which he fractured his hip and underwent surgical repair 1 week ago. He will be staying with his son for 2 weeks after he is discharged from the hospital, but he is eager to return to his own home. Once he is home, his son will visit nightly after work, he will receive Meals- on-Wheels once a day, and a home health care attendant will visit weekly to assist him with hygienic care until he is more independent. Mr. Moore’s wife died 3 years ago, but he has remained independent and continued his social functions. He lives in a small single-level house with hts dog and cat, and he enjoys gardening. Prior to fracturing his hip he walked his dog daily. You will be his home health care nurse.
While hospitalized, Mr. Moore experienced some mild confusion during the night, but his nurses decided not to restrain him. What are the best reasons for avoiding the use of restraints for clients such as Mr. Moore?
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3CTC. Mr. Moore is a 72-year-old widower who is recovering from a fall in which he fractured his hip and underwent surgical repair 1 week ago. He will be staying with his son for 2 weeks after he is discharged from the hospital, but he is eager to return to his own home. Once he is home, his son will visit nightly after work, he will receive Meals- on-Wheels once a day, and a home health care attendant will visit weekly to assist him with hygienic care until he is more independent. Mr. Moore’s wife died 3 years ago, but he has remained independent and continued his social functions. He lives in a small single-level house with hts dog and cat, and he enjoys gardening. Prior to fracturing his hip he walked his dog daily. You will be his home health care nurse.
While hospitalized, Mr. Moore experienced some mild confusion during the night, but his nurses decided not to restrain him. What are the best reasons for avoiding the use of restraints for clients such as Mr. Moore?
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3TYK. An 87-year-old man is admitted to the hospital for cellulitis of the left arm. He ambulates with a walker and takes a diuretic medication to control symptoms of fluid retention. Which intervention is most important to protect him from injury?
1.  Leave the bathroom light on.
2.  Withhold the client’s diuretic medication.
3.  Provide a bedside commode.
4.  Keep the side rails up.
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4CTC. Mr. Moore is a 72-year-old widower who is recovering from a fall in which he fractured his hip and underwent surgical repair 1 week ago. He will be staying with his son for 2 weeks after he is discharged from the hospital, but he is eager to return to his own home. Once he is home, his son will visit nightly after work, he will receive Meals- on-Wheels once a day, and a home health care attendant will visit weekly to assist him with hygienic care until he is more independent. Mr. Moore’s wife died 3 years ago, but he has remained independent and continued his social functions. He lives in a small single-level house with hts dog and cat, and he enjoys gardening. Prior to fracturing his hip he walked his dog daily. You will be his home health care nurse.
What strengths do you note about Mr. Moore that may protect him from injury when he returns home?
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4TYK. A mother and her 3-year-old live in a home built in 1932. Which NANDA nursing diagnosis is most applicable for this child?
1. Risk for Suffocation
2.  Risk for Injury
3.  Risk for Poisoning
4.  Risk for Disuse Syndrome
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5TYK. A 75-year-old client, hospitalized with a cerebrovascular accident (stroke), becomes disoriented at times and tries to get out of bed, but is unable to ambulate without help. What is the most appropriate safety measure?
1.  Restrain the client in bed.
2.  Ask a family member to stay with the client.
3.  Check the client every 15 minutes.
4.  Use a bed exit safety monitoring device.
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7TYK. A 75-year-old client, hospitalized with a cerebrovascular accident (stroke), becomes disoriented at times and tries to get out of bed, but is unable to ambulate without help. What is the most appropriate safety measure?
1.  Restrain the client in bed.
2.  Ask a family member to stay with the client.
3.  Check the client every 15 minutes.
4.  Use a bed exit safety monitoring device.
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8TYK. Medication errors can place the client at significant risk. Which practice(s) will help decrease the possibility of errors? Select all that apply.
1.  Hire only competent nurses.
2.  Improve the nurse’s ability to multitask.
3.  Establish a reporting system for “near misses."
4.  Communicate effectively.
5.  Create a culture of trust.
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9TYK. When planning to teach health care topics to a group of male adolescents, which topic should the nurse consider a priority?
1.  Sports contribute to an adolescent’s self-esteem.
2.  Sunbathing and tanning beds can be dangerous.
3.  Guns are the most frequently used weapon for adolescent suicide.
4.  A driver’s education course is mandatory for safety.
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