While preparing a client for surgery, the nurse marks the arm that is to be amputated and participates in a “time-out” procedure before the surgery begins.
Which sentinel event is this action intended to prevent?

The lack of healing of the stump.

Ineffective control of the client’s pain.

The removal of the wrong arm.

The client being mildly sedated.

Answer and Explanation

The Correct Answer is C

This action is intended to prevent a sentinel event, which is a patient safety event that results in death, permanent harm, or severe temporary harm. A sentinel event is a serious adverse event that signals the need for immediate investigation and response. Removing the wrong arm would be a devastating and irreversible outcome for the patient and the health care provider.

Choice A is wrong because the lack of healing of the stump is not a sentinel event. It is a possible complication of amputation that may be related to the natural course of the patient’s illness or underlying condition.

Choice B is wrong because ineffective control of the client’s pain is not a sentinel event. It is a quality of care issue that may affect the patient’s comfort and recovery, but it does not result in death, permanent harm, or severe temporary harm.

Choice D is wrong because the client being mildly sedated is not a sentinel event. It is a level of anesthesia that may be appropriate for some types of surgery, but it does not result in death, permanent harm, or severe temporary harm.

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Correct Answer is D

Explanation

Increasing regular weight-bearing activities can help prevent osteoporosis by stimulating bone formation and improving muscle strength. Weight-bearing activities are those that make your bones and muscles work against gravity, such as walking, jogging, dancing, or lifting weights.

Choice A is wrong because protecting the client’s bones with strict bedrest can actually increase the risk of osteoporosis by reducing bone density and muscle mass. Bedrest should be avoided unless medically necessary.

Choice B is wrong because providing the client with assisted range of motion exercises twice daily is not enough to prevent osteoporosis. While these exercises can help maintain joint mobility and flexibility, they are not weight bearing and do not stimulate bone formation.

Choice C is wrong because decreasing the amount of calcium in the client’s diet can also increase the risk of osteoporosis. Calcium is an essential mineral for bone health and adults need 700mg a day, which can be obtained from foods such as dairy products, leafy green vegetables, tofu, and dried fruit. Vitamin D is also important for bone health as it helps the body absorb calcium.

A. Chronic ocular pain related to stress, fatigue, and certain triggers. B. Pain and sensitivity in the upper extremities and neck. C. Dull joint pain that accompanies physical exertion and which is relieved with rest. D. Eight tender points in the legs and arms; insomnia; and fatigue.

Correct Answer is D

Explanation

This is because fibromyalgia is a disorder characterized by widespread musculoskeletal pain accompanied by fatigue, sleep, memory and mood issues. Fibromyalgia often co-exists with other conditions, such as irritable bowel syndrome, chronic fatigue syndrome, migraine and other types of headaches. One of the main symptoms of fibromyalgia is widespread pain that has lasted for at least three months. To be considered widespread, the pain must occur on both sides of your body and above and below your waist. The pain could also be felt in specific areas called tender points. These are places on the body where even light pressure causes pain. There are 18 possible tender points on the body. Having pain in at least 11 of these points is one way to help diagnose fibromyalgia.

Choice A is wrong because chronic ocular pain related to stress, fatigue, and certain triggers is not a typical symptom of fibromyalgia.

Ocular pain is more likely to be caused by other conditions, such as dry eye syndrome, glaucoma, or eye infections.

Choice B is wrong because pain and sensitivity in the upper extremities and neck are not enough to indicate fibromyalgia. The pain must be widespread and affect both sides of the body and above and below the waist. Choice C is wrong because dull joint pain that accompanies physical exertion and which is relieved with rest is not a characteristic of fibromyalgia. The pain associated with fibromyalgia is often described as a constant dull ache that does not improve with rest. It may also be accompanied by other symptoms, such as fatigue, cognitive difficulties, and sleep problems.

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While preparing a client for surgery, the nurse marks the arm that is to be amputated and participates in a “time-out” procedure before the surgery begins. Which sentinel event is this action intended to prevent?

Nursing Test Bank

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A client who is at risk for developing osteoporosis asks what can be done to decrease the risk of actually developing the disorder. Which intervention would be the most beneficial for this client?

Correct Answer is D

Explanation

The nurse identifies chronic pain as an appropriate nursing priority (or problem/diagnosis) for a client with fibromyalgia. Which manifestation did the client most likely report that caused the nurse to select this priority?

Correct Answer is D

Explanation

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While preparing a client for surgery, the nurse marks the arm that is to be amputated and participates in a “time-out” procedure before the surgery begins.
Which sentinel event is this action intended to prevent?