Nursing Practice II Exam || 100% Correct Solutions.
Safety Monitoring Devices correct answers Detects when clients are attempting to get out of bed
Magnetic Box Mobility Monitor correct answers Mounted on a bed or chair and connects with a
clip to clothing
Dual Sensor correct answers Pressure-sensitive combined with beam detector
Preventing Falls (Safety Assessment) correct answers Mobility status, emotional state, previous
accidents
Preventing Falls (Assessment Tool) correct answers Client completes a series of tasks important
for independent mobility, standing, walking, turning and sitting
Risk Factors (Poor Vision) correct answers Ensure eyeglasses are functional, ensure appropriate
lighting, mark doorways and edges of steps if needed, keep the environment tidy
Risk Factors (Cognitive Disfunction) correct answers Set safe limits to activities, remove unsafe
objects
Risk Factors (Impaired Gait or Balance) correct answers Wear shoes or well-fitted slippers with
nonskid soles, provide assistance with ambulation as needed, monitor gait and balance, ensure
uncluttered environment
Risk Factors (Difficulty Getting in and Out of Bed and Chairs) correct answers Encourage client
to request assistance, keep the bed in the low position, install grab bars in the bathroom, provide
a raised toilet seat
Risk Factors (Orthostatic Hypotension) correct answers Instruct client to rise slowly from a lying
to sitting to standing position and to stand in place for several seconds before walking
Risk Factors (Urinary Frequency or Receiving Diuretics) correct answers Provide bedside
commode, assist with voiding on a frequent and scheduled basis
Risk Factors (Weakness from Disease Process or Therapy) correct answers Encourage the client
to summon help, monitor activity tolerance
Risk Factors (Current Medication) correct answers Attach side rails to the bed if appropriate,
keep the rails in place when the bed is in the lowest position or place pads at the side of the bed,
monitor orientation and alertness status
Preventing Falls In Health Care Settings correct answers On admission orient clients to their
surroundings and explain the call system, carefully asses clients' ability to ambulate and transfer,
encourage clients to wear non skid footwear, put side tables and trays close to bed to prevent
over reaching
, Restraints correct answers Protective devices used to limit the physical activity of the client or
restrict movement of a part of the body
Reasons for Restraints correct answers To avoid and/or prevent purposeful or accidental harm to
the client or to prevent a client from harming others
Classification of Restraints correct answers Physical, Chemical, Environmental
Chemical Restraints correct answers Psychoactive medication used to intentionally inhibit a
particular behaviour or movement not treating an illness
Physical Restraints correct answers Any device placed on or near one's body that limits voluntary
movement or access to one's own person
Environmental Restraints correct answers Modification of a client's surroundings limiting their
freedom of movements, locks on a door, pieces of furniture or large plants as barriers
Nursing Considerations (Use of Restraint Causes) correct answers Increased agitation, does not
control behaviour, loss of dignity, autonomy, freedom
Policy Direction: Least Restraint correct answers Preservation of the client's dignity and
enhances client's quality of life
CNO Practice Standard: Restraint Assumptions correct answers Nursing interventions promote
well-being, least restraint does not mean accepting nurse abuse, nurses involve clients or
subsitiute in planning, consent is essential
Least Restraint correct answers Means all possible alternative interventions are exhausted before
deciding to use restraints
Nursing Responsibilities (CNO) correct answers Understand the client's behaviour, develop an
induvidual plan of care, collaborate with health care team, evaluate plan of care and make
changes, use least restrictive restraints
Belt Restraint correct answers Used to ensure the safety of all clients who are being moved on
stretchers or wheelchairs
Vest Restraint correct answers Used to ensure the safety of confused or sedated clients in beds or
wheelchairs
Mitt Restraint correct answers Used to prevent clients of any age from using their hands or
fingers to scratch and injure themsevles
Limb Restraint correct answers Used to immobilize limbs for therapeutic reasons (example: to
maintain IV infusion)
Safety Monitoring Devices correct answers Detects when clients are attempting to get out of bed
Magnetic Box Mobility Monitor correct answers Mounted on a bed or chair and connects with a
clip to clothing
Dual Sensor correct answers Pressure-sensitive combined with beam detector
Preventing Falls (Safety Assessment) correct answers Mobility status, emotional state, previous
accidents
Preventing Falls (Assessment Tool) correct answers Client completes a series of tasks important
for independent mobility, standing, walking, turning and sitting
Risk Factors (Poor Vision) correct answers Ensure eyeglasses are functional, ensure appropriate
lighting, mark doorways and edges of steps if needed, keep the environment tidy
Risk Factors (Cognitive Disfunction) correct answers Set safe limits to activities, remove unsafe
objects
Risk Factors (Impaired Gait or Balance) correct answers Wear shoes or well-fitted slippers with
nonskid soles, provide assistance with ambulation as needed, monitor gait and balance, ensure
uncluttered environment
Risk Factors (Difficulty Getting in and Out of Bed and Chairs) correct answers Encourage client
to request assistance, keep the bed in the low position, install grab bars in the bathroom, provide
a raised toilet seat
Risk Factors (Orthostatic Hypotension) correct answers Instruct client to rise slowly from a lying
to sitting to standing position and to stand in place for several seconds before walking
Risk Factors (Urinary Frequency or Receiving Diuretics) correct answers Provide bedside
commode, assist with voiding on a frequent and scheduled basis
Risk Factors (Weakness from Disease Process or Therapy) correct answers Encourage the client
to summon help, monitor activity tolerance
Risk Factors (Current Medication) correct answers Attach side rails to the bed if appropriate,
keep the rails in place when the bed is in the lowest position or place pads at the side of the bed,
monitor orientation and alertness status
Preventing Falls In Health Care Settings correct answers On admission orient clients to their
surroundings and explain the call system, carefully asses clients' ability to ambulate and transfer,
encourage clients to wear non skid footwear, put side tables and trays close to bed to prevent
over reaching
, Restraints correct answers Protective devices used to limit the physical activity of the client or
restrict movement of a part of the body
Reasons for Restraints correct answers To avoid and/or prevent purposeful or accidental harm to
the client or to prevent a client from harming others
Classification of Restraints correct answers Physical, Chemical, Environmental
Chemical Restraints correct answers Psychoactive medication used to intentionally inhibit a
particular behaviour or movement not treating an illness
Physical Restraints correct answers Any device placed on or near one's body that limits voluntary
movement or access to one's own person
Environmental Restraints correct answers Modification of a client's surroundings limiting their
freedom of movements, locks on a door, pieces of furniture or large plants as barriers
Nursing Considerations (Use of Restraint Causes) correct answers Increased agitation, does not
control behaviour, loss of dignity, autonomy, freedom
Policy Direction: Least Restraint correct answers Preservation of the client's dignity and
enhances client's quality of life
CNO Practice Standard: Restraint Assumptions correct answers Nursing interventions promote
well-being, least restraint does not mean accepting nurse abuse, nurses involve clients or
subsitiute in planning, consent is essential
Least Restraint correct answers Means all possible alternative interventions are exhausted before
deciding to use restraints
Nursing Responsibilities (CNO) correct answers Understand the client's behaviour, develop an
induvidual plan of care, collaborate with health care team, evaluate plan of care and make
changes, use least restrictive restraints
Belt Restraint correct answers Used to ensure the safety of all clients who are being moved on
stretchers or wheelchairs
Vest Restraint correct answers Used to ensure the safety of confused or sedated clients in beds or
wheelchairs
Mitt Restraint correct answers Used to prevent clients of any age from using their hands or
fingers to scratch and injure themsevles
Limb Restraint correct answers Used to immobilize limbs for therapeutic reasons (example: to
maintain IV infusion)
