A nurse is assisting with the care of an adolescent. Which of the following statements should the nurse identify as high-risk behaviors?

B. Stool results: A positive hemoccult test indicates gastrointestinal bleeding, likely due to a peptic ulcer. Immediate follow-up is needed to assess for ongoing blood loss and the potential for hemorrhagic complications.

C. Heart rate: The tachycardia (118/min) suggests a compensatory response to hypovolemia from gastrointestinal bleeding. This requires prompt intervention to prevent hemodynamic instability.

F. Blood pressure: Hypotension (90/50 mm Hg) is concerning for volume depletion due to chronic or active gastrointestinal bleeding. This requires immediate follow-up to prevent shock.

G. Hemoglobin and hematocrit: A hemoglobin of 9.1 g/dL and hematocrit of 27% indicate anemia, likely due to gastrointestinal blood loss. Further evaluation and potential blood transfusion may be required.

H. Current medications: Ibuprofen use is a major risk factor for peptic ulcer disease and gastrointestinal bleeding. Immediate follow-up is needed to discontinue NSAIDs and initiate appropriate ulcer management.

Incorrect:

A. Respiratory rate: A rate of 18/min is within the normal range and does not require urgent follow-up.

D. Temperature: A temperature of 37.5°C (99.5°F) is slightly elevated but not clinically significant for immediate intervention.

E. WBC count: The WBC count is within the normal range, making it less of an immediate concern.

A) Staff members used a class A fire extinguisher during an electrical fire.
This response indicates that the safety plan is effective because it shows that the staff used the correct type of fire extinguisher for the fire they encountered. Class A fire extinguishers are designed for ordinary combustibles (e.g., wood, paper, cloth), but using a fire extinguisher that is correctly suited to the fire type demonstrates that the staff are trained and prepared to respond appropriately in an emergency. For electrical fires, however, a Class C fire extinguisher should be used. This suggests a review of fire safety plan training might be necessary to align fire extinguisher types with fire classes.

B) Staff members review the locations of fire extinguishers every 2 to 3 years.
Reviewing the locations of fire extinguishers every 2 to 3 years is not an adequate frequency. Fire safety protocols should be reviewed more frequently to ensure that staff are consistently aware of fire extinguisher locations. Routine and more frequent checks (e.g., annually) are required to ensure proper preparedness in an emergency.

C) An evacuation was ordered during a fire when fire extinguishers were not effective.
While evacuations are necessary in certain situations, an evacuation being ordered because fire extinguishers were ineffective could indicate that the safety plan was not properly executed or that there was an issue with fire extinguisher maintenance or staff training. The effectiveness of fire safety plans should reduce the need for evacuations due to inadequate response efforts.

D) Fire alarms in the facility have the same sound as other alarms.
Fire alarms should have a distinct sound that differentiates them from other types of alarms (e.g., medical or security alarms). If fire alarms have the same sound as other alarms, it could create confusion in an emergency, undermining the effectiveness of the safety plan. The alarm system should be unique and easily identifiable.