M.E.'s husband states, "How are you going to take care of her? She wanders around all night long. She
cannot find her way to the bathroom in a house she has lived in for 43 years.
She cannot be trusted to be
alone anymore; she almost burnt the house down. We're all exhausted; there are three of us, and we can't
keep up with her." You acknowledge how exhausted they must be from trying to keep her safe. You tell the
family that Alzheimer units have been created to provide a structured, safe environment.
Describe specific nursing interventions to place in M.E.'s plan of care that are part of
National Patient Safety Goals aimed at minimizing her risk of falling.
• Keep necessary items, including water, phone, and call light, within easy reach.
• Keep bed in its lowest position. Side rail position (up or down) will vary with the patient.
• Use appropriate personal safety devices, including bed alarms, a mat alarm under a bedside rug, or
a motion detector.
• Maintain an uncluttered environment to minimize the risk of environmental confusion and
tripping. Ensure adequate lighting to help prevent falls in the dark.
• Encourage her to use low-heeled, nonskid shoes for walking. Use gestures or turn her body in the
direction she is to go.
• Check her at frequent intervals. If necessary, move her closer to the nursing station, away from
stairways and unit exits, or seat her in a chair at nursing station.
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Which of the following would be considered a failure of proper implementation?
a. Not identifying and analyzing symptoms appropriately b. Not documenting the patient's response to pain medication c. Not recognizing a malfunctioning chest tube d. Not asking the patient about code or no code wishes
A patient is diagnosed with otosclerosis. The nurse plans interventions related to which type of hearing loss?
1. Sensorineural 2. Mixed 3. Conductive 4. Cochlear
When the Goodenough-Harris Drawing Test is administered to a child, the evaluator principally observes the:
a. presence and form of body parts. b. gender and race of the person drawn. c. approximate age and posture of the person drawn. d. length of time needed to draw a stick man.
Attentive listening is defined as:
a. keeping confidentiality by not repeating what you hear to other people b. paying attention to what you hear and showing the speaker that you are listening c. writing down what the speaker says and putting the notes in the medical record d. informing the parents or legal guardians of specific details you hear from the speaker