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.
The nurse assesses the patient's ability to use the walker correctly
Nurse Sandy
Effects of nursing rounds on patient safety
Instructing a Patient on Breast Self-Examination