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50 Cards in this Set

  • Front
  • Back
Factors that affect client safety?
health status
sensory-perceptual alterations
cognitive awareness
emotional state
safety awareness/knowledge
environmental hazards
common hazards in the home include?
storage of medications and toxic substances.
slippery floors
throw rugs
slippery tubs'/showers
frayed electrical cords
lack of smoke detectors
What sequence do you follow when a fire occurs in the health care setting?
-protect and evacuate clients
-report the fire
-contain the fire
-extinguish the fire
What is the main cause of poisoning in children?
Improper storage of toxic substances and inadequate supervision
What is the universal sign of choking?what are the interventions?
victims grasp and points to the neck and throat without speaking.
-abdominal thrust
When should restraints be used?
Last resort, with md order.
how should one document in chart the use of restraints?
1.reason and duration
2.client must agreee to be restrained
What will increase the risk for in injury in an adult?
-sensory and mobility deficits
What will increase the risk for injury in a child?
-lack of knowledge and experience to maintain safety
Lifestyle: what factors increase the risk for injury?
-living in a high-crime hood
-access to guns
-lack of income to make repairs
-illicit drug use
-risk-taking behavior i.e(driving while intoxicated, no seat belt)
Mobility and health status:what factors increase the risk for injury?
-Muscle weakness
-poor balance or coordination
Sensory-perceptual alterations; what factors increase risk for injury?
-impaired touch perception
-impaired vision
-impaired hearing
Cognitive awareness: what factors increase risk for injury?Which ones may be caused by disease process or medications such as narcotics?
-Impaired awareness(lack of sleep)
-unconscious states
-altered judgement
Emotional state: what factors increase the risk for injury?
-stress reduces concentration and awareness of external stimuli
-depression causes slower thinking and reation to environmental stimuli.
Safety awareness; what factors increase the risk for injury?
clients in new environment, may need specific safety info
ex. not to disconnect iv tube
Environmental factor: that increase risk for injury?
-Home:slippery bathtubs
-work:machinern, chemicals
-community: unsafe water,poor street lighting
Name common hazard in the home?
-toxic substances(improper storage)
-Uneven,broken walkways;loose stairs
-slippery floors,tubs
-furniture with sharp corners
-Pilot lights in need of repair
-Inadequate lighting
-absence of smoke detectors
-no method to call for help
Name nursing diagnoses related to safety in the home?
-knowledge deficit(accident prevention)
-Risk for:injury,poisoning,suffocation,trauma,and aspiration
Scalds and burns;What clients are at risk?
-those whose skin has decreased ability to sense temperature.
In the home scalds are caused by?
-pot handles
-electric appliances
-excessively high temp in water heater.
Fires are classified according to the material that is burning?
Class A:
Class B:
Class C:
1. pater, wood upholstery, rags, ordinary rubbish
2.flammable liquids and gases
3.electrical fires
What sequence do you follow when a fire occurs in the health care setting?
-protect and evacuate patients
-report the fire
-contain the fire
-extinguish the fire
In the home, what are preventative measures to follow?
-keep emergency numbers near the telephone
-have a family exit plan;fire drills
-maintain operable smoke alarms
-keep fire extinguishers
If a fire occurs what do you do?
-close windows and doors
-cover mouth and nose with damp cloth when leaving through a smoky area
-bend over and keep head as close to the floor as possible to avoid the heaviest smoke.
Where do most falls occur?
Who is at risk?
infants and older adults
What are risk factors for falls?
-poor vision
-cognitive dysfunction
-impaired transfer mobility
-orthostatic hypotension
-urinary frequency
What are therapeutic nursing actions to prevent falls?
-ON admission, orient clients to the sorroundings.
-use a risk asses tool\
-sr up,bed low, call light in reach
-lock wheels,stretchers,beds\
-provide nonskid footwear
-use bed or chair safety sensors
-keep floor free of cluter
-provide adequate lighting
What are therapeutic nursing interventions for poisoning?
-Teach parents to childproof the home
-place poison warning stickers on toxic substances
-education on risk behaviors
-safeguard for adults
What to do if poison occurs? poison by searching for the container poison control center
3.keep person quiet,lie on side to prevent aspiration
4. follow instructions from poison control center
Physiological effects of noise include?
-incresed heart and RR rates
increased muscle tension and activity
-hearing impairment
Therapeutic nursing interventions for electrical safety?
-check for frayed cords
-do not overload outlets and fuse boses
-use only grounded outlets and plugs
-do not use electric appliances near sinks or other wet areas
-use protective cover over wall outlets
-disconnect appliances before cleaning or repairing them.
devices which limit a clients activity and are primarily used to prevent injury to the client,staff,another person, or property?
Any physical,manual or, mechanical method or device attached to the body to restrict movement?
Medications, such as neuroleptics, sedatives, anxiolytics are what type of restraints?
When should chemical restraints be used?
-last resort, disruptive oriented elders
Safety measures when using restraints?
-remove or replace frequently
-pad bony prominences
-perform neurological and circulatory evaluations.
-allow enough slck on the staps
-use knots easily release
-keep loose enough to slip 2 fingers
-Never tie on side rails
-explain need for restraints
-never leave client alone when restraints are off.
-assess every 30 min
Criteria for selecting restraints?
-restrict movement as little as possible
-does not interfere with the clients treatment
-is easily changed
-is safe for client
-restrains only to extent necessary
-fits properly
How to document restraints?
-The behavior that made the restraint necessary
-The type of restraint used
-explanations given to pt n fam
-the clients consent
-exact times of application and removal
-client behavior while restr
-type and freq of care given
i.e circulation asses and ROM
for confused or sedated clients in beds and wheelchairs.
How do you put a vest restraint on ?
1.sized to fit client
2.tie with a half-bow knot to bed frame or chair leg not tie to the head of the bed not tie so tight as to restrict breathing
For all clients being moved by stretcher or wheelchair. Apply even when side rails are up.
to prevent confused clients and children from scratching and injuring themselves(pulling out tubing)?
Cloth restraints primarity used to maintain an intravenous infusion. Pad bony prominence tie with half bow knot secure other end to the moveable bed frame.
Rigid restraint used to keep infants and children from flexing their elbows to touch or scratch the face or head. Be sure none of the tongue depressors in the restraint are broken;be sure the ends are padded
special folding of a blanket or sheet around a child's body to prevent movement during procedures such a eye irrigation
what increases stability and balance?
-a wide base of suppport
-a low center of gravity
The efficient, coordinated, and safe use of the body as a machine and as a means of locomotion.
an object is the center of its mass. In humans, it is at the center of the pelvis about midway b/w the umbilicus and symphysis pubis
the vertical line passing through the center of gravity
the foundation that provides the object persons stability