The nurse has placed a yellow armband on a 70-year-old patient. ...

[ARLKQ]

The nurse has placed a yellow armband on a 70-year-old patient. Which observation by the nurse will indicate the patient has an understanding of this action?
 
  a. The patient removes the armband to bathe.
  b. The patient wears the red nonslip footwear.
  c. The patient insists on taking a water pill in the evening.
  d. The patient who is allergic to penicillin asks the name of a new medicine.

Question 2

A confused patient is restless and continues to try to remove the oxygen cannula and urinary catheter. What is the priority nursing diagnosis and intervention to implement for this patient?
 
  a. Risk for injury: Check on patient every 15 minutes.
  b. Risk for suffocation: Place Oxygen in Use sign on door.
  c. Disturbed body image: Encourage patient to express concerns about body.
  d. Deficient knowledge: Explain the purpose of oxygen therapy and the urinary catheter.

[yeungji]

Answer to Question 1

ANS: B
A yellow armband is an alert for high risk of falls. Red nonslip footwear helps to grip the floor and decreases the chance of falling. The communication armband should stay in place and should not be removed, so that all members of the interdisciplinary team have the information about the high risk for falls. A red armband indicates an allergy. Give diuretics (water pill) in the morning to decrease risk of falls during the nightwhen most falls occur.

Answer to Question 2

ANS: A
The priority nursing diagnosis is Risk for injury. This patient could cause harm to self by interrupting the oxygen therapy or by damaging the urethra by pulling the urinary catheter out. Before restraining a patient, it is important to implement and exhaust alternatives to restraint. Alternatives can include more frequent observations. This patient may have deficient knowledge; educating the patient about treatments could be considered as an alternative to restraints. However, the nursing diagnosis of highest priority is risk for injury. This scenario does not indicate that the patient has a disturbed body image or that the patient is at risk for suffocation.

[ARLKQ]

Excellent

[marict]

Gracias!