Chapter 12 Skills in Clinical Nursing 8th Edition by Audrey J. Berman- Shirlee Snyder

Chapter 12 Skills in Clinical Nursing 8th Edition by Audrey J. Berman- Shirlee Snyder

 

Complete Chapter Questions With Answers

 

Sample Questions Are Posted Below

 

MULTIPLE CHOICE.  Choose the one alternative that best completes the statement or answers the question.

• The nurse administers an antianxiety (anxiolytic) medication to a client who has a diagnosis of 1) dementia who has been harming The nurse recognizes this is a/n:

1. A) Chemical B) Physical restraint.
2. C) Illegal D) Seizure precaution.

Answer: A

Explanation: A)       Administering a medication for the purpose of controlling socially disruptive behavior is a form of chemical restraint. Physical restraints are visible appliances applied to the client’s body to control behavior. While restraints are not illegal, they must be used following strict facility protocols. Seizure precautions are safety measures taken by the nurse to protect the client from injury if a seizure occurs.

Cognitive Level: Application

Client Need: Physiological Integrity

Nursing Process: Implementation

1. Administering a medication for the purpose of controlling socially disruptive behavior is a form of chemical Physical restraints are visible appliances applied to the client’s body to control behavior. While restraints are not illegal, they must be used following strict facility protocols. Seizure precautions are safety measures taken by the nurse to protect the client from injury if a seizure occurs.

Cognitive Level: Application

Client Need: Physiological Integrity

Nursing Process: Implementation

1. Administering a medication for the purpose of controlling socially disruptive behavior is a form of chemical Physical restraints are visible appliances applied to the client’s body to control behavior. While restraints are not illegal, they must be used following strict facility protocols. Seizure precautions are safety measures taken by the nurse to protect the client from injury if a seizure occurs.

Cognitive Level: Application

Client Need: Physiological Integrity

Nursing Process: Implementation

1. Administering a medication for the purpose of controlling socially disruptive behavior is a form of chemical Physical restraints are visible appliances applied to the client’s body to control behavior. While restraints are not illegal, they must be used following strict facility protocols. Seizure precautions are safety measures taken by the nurse to protect the client from injury if a seizure occurs.

Cognitive Level: Application

Client Need: Physiological Integrity

Nursing Process: Implementation

Objective: Learning Outcome 12-1: Define the key terms used in the skills of preventing falls and restraining

clients.

 

• The nurse is caring for a client who keeps pulling at his IV and urinary Restraints are 2) applied that prevent the client from being able to grasp the tubing. This type of restraint is a:

1. A) Jacket B) Limb restraint. C) Mitt restraint.               D) Waist restraint.

Answer: C

Explanation: A)      The mitt restraint is like a mitten that goes over the hand and limits the ability of the fingers to grasp while not limiting arm movement. Limb restraints tie the arm to the bed and limit arm movement. A jacket restraint is applied to the client’s chest, and ties to the bed to keep the client from sitting up or getting out of bed. Waist restraints tie around the client’s waist and then to the bed to limit movement. Cognitive Level: Application

Client Need: Safe, Effective Care Environment

Nursing Process: Implementation

1. The mitt restraint is like a mitten that goes over the hand and limits the ability of the fingers to grasp while not limiting arm Limb restraints tie the arm to the bed and limit arm movement. A jacket restraint is applied to the client’s chest, and ties to the bed to keep the client from sitting up or getting out of bed. Waist restraints tie around the client’s waist and then to the bed to limit movement. Cognitive Level: Application

Client Need: Safe, Effective Care Environment

Nursing Process: Implementation

1. The mitt restraint is like a mitten that goes over the hand and limits the ability of the fingers to grasp while not limiting arm Limb restraints tie the arm to the bed and limit arm movement. A jacket restraint is applied to the client’s chest, and ties to the bed to keep the client from sitting up or getting out of bed. Waist restraints tie around the client’s waist and then to the bed to limit movement. Cognitive Level: Application

Client Need: Safe, Effective Care Environment

Nursing Process: Implementation

1. The mitt restraint is like a mitten that goes over the hand and limits the ability of the fingers to grasp while not limiting arm Limb restraints tie the arm to the bed and limit arm movement. A jacket restraint is applied to the client’s chest, and ties to the bed to keep the client from sitting up or getting out of bed. Waist restraints tie around the client’s waist and then to the bed to limit movement. Cognitive Level: Application

Client Need: Safe, Effective Care Environment

Nursing Process: Implementation

Objective: Learning Outcome 12-1: Define the key terms used in the skills of preventing falls and restraining clients.

 

• Which of the following actions performed by the nurse will not reduce the risk of the client falling? 3)

1. Orient clients to the unit and explain how the call bell system
2. Encourage clients to use call bells for assistance and ensure that the call bell is within easy

reach.

1. Place overbed and bedside tables out of the
2. Use nonskid mats in the tub or

Answer: C

Explanation: A)      Tables should be placed within the reach of the client to avoid having her reach for something and fall out of bed. All of the other actions are correct strategies for

reducing the risk of falls.

Cognitive Level: Application

Client Need: Safe, Effective Care Environment

Nursing Process: Implementation

1. Tables should be placed within the reach of the client to avoid having her reach for something and fall out of All of the other actions are correct strategies for

reducing the risk of falls.

Cognitive Level: Application

Client Need: Safe, Effective Care Environment

Nursing Process: Implementation

1. Tables should be placed within the reach of the client to avoid having her reach for something and fall out of All of the other actions are correct strategies for

reducing the risk of falls.

Cognitive Level: Application

Client Need: Safe, Effective Care Environment

Nursing Process: Implementation

1. Tables should be placed within the reach of the client to avoid having her reach for something and fall out of All of the other actions are correct strategies for

reducing the risk of falls.

Cognitive Level: Application

Client Need: Safe, Effective Care Environment

Nursing Process: Implementation

Objective: Learning Outcome 12-2: Explain measures to prevent falls in hospitals and ambulatory settings.

• The nurse is preparing to ambulate the client in the Which of the following would be an 4) effective strategy to reduce the client’s risk of falls?

1. Encourage client to wear nonskid
2. Caution the client about cords or clutter on the
3. Encourage the client to continue walking when he complains of feeling
4. Act as the client’s means of support instead of using a walker to provide additional

Answer: A

Explanation: A)      The client should be encouraged to wear nonskid footwear to prevent slipping on the floor. Instead of cautioning clients about cords and clutter, they should be removed to reduce risk. When a client says she is tired and can’t walk farther, encouraging her to continue could result in a fall. It is safer to allow clients to use familiar ambulation assistants when needed instead of the nurse acting to support

the client.

Cognitive Level: Application

Client Need: Safe, Effective Care Environment

Nursing Process: Implementation

1. The client should be encouraged to wear nonskid footwear to prevent slipping on the Instead of cautioning clients about cords and clutter, they should be removed to reduce risk. When a client says she is tired and can’t walk farther, encouraging her to continue could result in a fall. It is safer to allow clients to use familiar ambulation assistants when needed instead of the nurse acting to support

the client.

Cognitive Level: Application

Client Need: Safe, Effective Care Environment

Nursing Process: Implementation

1. The client should be encouraged to wear nonskid footwear to prevent slipping on the Instead of cautioning clients about cords and clutter, they should be removed to reduce risk. When a client says she is tired and can’t walk farther, encouraging her to continue could result in a fall. It is safer to allow clients to use familiar ambulation assistants when needed instead of the nurse acting to support

the client.

Cognitive Level: Application

Client Need: Safe, Effective Care Environment

Nursing Process: Implementation

1. The client should be encouraged to wear nonskid footwear to prevent slipping on the Instead of cautioning clients about cords and clutter, they should be removed to reduce risk. When a client says she is tired and can’t walk farther, encouraging her to continue could result in a fall. It is safer to allow clients to use familiar ambulation assistants when needed instead of the nurse acting to support

the client.

Cognitive Level: Application

Client Need: Safe, Effective Care Environment

Nursing Process: Implementation

Objective: Learning Outcome 12-2: Explain measures to prevent falls in hospitals and ambulatory settings.

• The nurse is working in a long-term care facility on a locked Alzheimer’s Which of the 5) following clients might require restraints?

1. The client who keeps getting out of bed at night and wandering the halls
2. The client who enters another client’s room without reason and watches TV with the client in

that room

1. The elderly client who spits at staff when they enter the room
2. The client who has numerous self-imposed scratches on his extremities

Answer: D

Explanation: A)      The client who has scratches might require a mitt restraint to prevent him from

causing further injury. Wandering is a common behavior in clients with

Alzheimer’s disease, and would not require restraints if the client is not harming himself or others. Bed or door alarms might be indicated to alert the staff when the client wanders, but the use of restraints would not be warranted. The client who is

spitting would not require restraints, although staff should wear personal

protective equipment when entering the room.

Cognitive Level: Analysis

Client Need: Safe, Effective Care Environment

Nursing Process: Planning

1. The client who has scratches might require a mitt restraint to prevent him from causing further Wandering is a common behavior in clients with Alzheimer’s disease, and would not require restraints if the client is not harming himself or others. Bed or door alarms might be indicated to alert the staff when the client wanders, but the use of restraints would not be warranted. The client who is spitting would not require restraints, although staff should wear personal protective equipment when entering the room.

Cognitive Level: Analysis

Client Need: Safe, Effective Care Environment

Nursing Process: Planning

1. The client who has scratches might require a mitt restraint to prevent him from causing further Wandering is a common behavior in clients with Alzheimer’s disease, and would not require restraints if the client is not harming himself or others. Bed or door alarms might be indicated to alert the staff when the client wanders, but the use of restraints would not be warranted. The client who is spitting would not require restraints, although staff should wear personal protective equipment when entering the room.

Cognitive Level: Analysis

Client Need: Safe, Effective Care Environment

Nursing Process: Planning

1. The client who has scratches might require a mitt restraint to prevent him from causing further Wandering is a common behavior in clients with Alzheimer’s disease, and would not require restraints if the client is not harming himself or others. Bed or door alarms might be indicated to alert the staff when the client wanders, but the use of restraints would not be warranted. The client who is spitting would not require restraints, although staff should wear personal protective equipment when entering the room.

Cognitive Level: Analysis

Client Need: Safe, Effective Care Environment

Nursing Process: Planning

Objective: Learning Outcome 12-3: Identify indications and contraindications for restraining clients.