A nurse is collecting data from a client who has an acute condition. Which of the following findings should the nurse identify as increasing the risk for potential client injuries?

Hearing acuity intact

Oriented to person only

Full range of motion bilateral lower extremities

Ability to use call light

Answer and Explanation

The Correct Answer is B

A)   Hearing acuity intact - Intact hearing acuity does not directly increase the risk for potential client injuries.
B)   Oriented to person only - Being oriented to person only may indicate confusion or disorientation, which can increase the risk for potential client injuries due to impaired decision-making or awareness of surroundings.
C)   Full range of motion bilateral lower extremities - Having a full range of motion in the lower extremities does not directly increase the risk for potential client injuries.
D)   Ability to use call light - The ability to use a call light indicates the client's ability to seek assistance, which reduces the risk for potential client injuries.

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Correct Answer is B

Explanation

A. Assign different nurses to provide care for clients each day- Continuity of care is important for building rapport and trust between clients and their healthcare providers.
B. Restrict the number of visitors for clients- Limiting visitors can help reduce noise and stress for clients, promoting rest and recovery.

C. Offer the clients many choices regarding care- While autonomy is important, offering too many choices can be overwhelming for clients, especially in a stressful environment like an acute care unit.
D. Turn on loud music in client care areas- Loud music can increase stress and discomfort for clients, especially those who are trying to rest or recover.

A. Placing the restraint across the client's chest B. Applying the restraint over the client's gown C. Using a quick-release tie to secure the restraint D. Tying the restraint to the bed frame

Correct Answer is A

Explanation

A) Placing the restraint across the client's chest - This is not a safe practice since it can restrict breathing increasing the risk of asphyxiation.
B) Applying the restraint over the client's gown - Restraints should be applied over the clients gown and not directly to the client's skin to prevent friction and skin breakdown.
C) Using a quick-release tie to secure the restraint - Quick-release ties are important for ensuring that restraints can be quickly removed in case of an emergency.
D) Tying the restraint to the bed frame – Tying restraints on the bed frame is the recommended practice. Restraints should not be tied on the bed rails to avoid injuries if the side rails are released.

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A nurse is collecting data from a client who has an acute condition. Which of the following findings should the nurse identify as increasing the risk for potential client injuries?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is B

Explanation

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Correct Answer is A

Explanation

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