A nurse is assisting with conducting a home
hazard assessment for a client who has a) tie the restraints to the siderails on the client's
dementia. Which of the following findings bed
indicates an understanding of home safety? b) remove the restraints with each vital sign
check
a) an extension cord is secured under a rug c) use the square knot to secure the restraints
b) the edges of stairs are marked with brightly d) make sure one finger can fit under the
colored tape restraints - ANSWER -b) remove the
c) a toaster is plugged in when not in use restraints with each vital sign check
d) the water heater is set to 55 degrees C -
ANSWER -b) the edges of stairs are
marked with brightly colored tape A nurse discovers a small fire in a client's room.
After removing the client to safety, which of the
following actions should the nurse take next?
A nurse is preparing to conduct a fall risk
screening on a client. Which of the following a) extinguish the fire
variables will the nurse use to evaluate the b) close the windows in the client's room
client? Select all that apply c) close the client's door
d) activate the fire alarm - ANSWER -d)
a) fall history activate the fire alarm
b) medical diagnosis
c) use of assistive devices
d) mental status A nurse is caring for a client who is at risk for
e) do-not-resuscitate status - ANSWER -a) suicide. Which of the following actions should the
fall history nurse take? Select all that apply
b) medical diagnosis
c) use of assistive devices a) place the client on round-the-clock surveillance
d) mental status b) remove the objects from the room that the
client could use to arm themselves
c) search items brought into the client's room by
A nurse is assisting with teaching about warning visitors
signs from a co-worker that might indicate future d) refrain from asking the client if they intend to
workplace violence. Which of the following harm themselves
behaviors should the nurse include? e) screen the client for suicide ideation -
ANSWER -a) place the client on round-the-
a) legitimate absenteeism clock surveillance
b) strict adherence to facility policies b) remove the objects from the room that the
c) consistent adequate work performance client could use to arm themselves
d) frequent reports of not being treated fairly - c) search items brought into the client's room by
ANSWER -d) frequent reports of not being visitors
treated fairly e) screen the client for suicide ideation
A nurse is caring for a client who has a A nurse is planning to use the identify, situation,
prescription for wrist restraints. Which of the background, assessment, recommendation,
following actions should the nurse take? read-back (ISBARR) tool to communicate with a
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