Which statement is correct about falls? Most falls
a. occur during the day c. involve wheelchairs
b. occur in the kitchen or bathroom d. involve patients with poor hearing
C
A great majority of falls: occur in the evening; occur in the patient's room; involve wheelchairs; involve unattended patients; involve patients with poor footwear; occur with poor lighting; involve patients with poor vision; and occur with patients experiencing neuromuscular impairment.
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The nursing diagnosis is: Impaired Memory related to fluid and electrolyte imbalances A.M.B. inability to recall recent events. Which of the following goals/outcomes must be included on the care plan?
1) Checks current medications for mind-altering side effects 2) Demonstrates use of techniques to help with memory loss 3) Drinks at least 1500 cc of fluid per day 4) Takes electrolyte supplements with meals
The client continues to ask questions about a surgical wound. The client states, "I think I would like help the first time I look at my wound." This is an example of:
1. Adaptation 2. Perception 3. Organizing 4. Guided response
When a patient's personal relationship with family members suddenly becomes very strained, you recognize that the patient is probably experiencing
A. denial. B. anger. C. shock. D. depression.
A toddler is admitted to the surgical unit for a planned closure of a temporary colostomy. Which medical prescription should the nurse question?
1. Clear liquids today. NPO tomorrow 2. Type and cross-match for 1 unit of packed red blood cells. 3. Rectal temperatures every 4 hours 4. Start an intravenous line with D5NS at 20 mL per hour.