The nurse is monitoring for risk for injuries identified in the healthcare environment. Which unsafe healthcare environment finding(s) will require action from the nurse? Select all that apply

Frayed electrical cords

Call light within reach for all clients

Light bulbs burnt out in client rooms

Client rooms that are clear of debris

Alarms not functioning properly

Hallways cluttered with equipment and beds

Answer and Explanation

Correct Answer : A,C,E,F

A. Frayed electrical cords: Frayed cords pose a serious risk of electrical shock or fire. The nurse must report and ensure repair or replacement immediately to maintain a safe environment for both clients and staff.

B. Call light within reach for all clients: Having the call light accessible promotes client safety and independence. This is a safe practice and does not require corrective action.

C. Light bulbs burnt out in client rooms: Burnt-out light bulbs can lead to poor visibility, increasing the risk of trips, falls, and other accidents. The nurse should ensure that lighting is restored promptly to maintain a safe environment.

D. Client rooms that are clear of debris: Clear rooms reduce fall risks and support a safe environment. This indicates proper housekeeping and does not require intervention.

E. Alarms not functioning properly: Nonfunctioning alarms, such as bed or chair alarms, compromise patient safety by preventing timely alerts for at-risk clients. The nurse must have these repaired or replaced immediately.

F. Hallways cluttered with equipment and beds: Cluttered hallways obstruct safe movement, creating fall hazards and delaying emergency responses. Immediate action is needed to clear pathways and maintain safety standards.

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Correct Answer is B

Explanation

A. Identify the needed nursing actions to address the client's health problem: Planning and determining interventions occur in the planning phase, not during assessment. Assessment focuses on data collection rather than action implementation.

B. Interview the client about current and past health history: Collecting subjective and objective information through interviews, observation, and examination is the core of the assessment phase. This information forms the foundation for identifying problems and planning care.

C. Measure the success of the care goals: Evaluating whether goals have been met is part of the evaluation phase. It occurs after interventions have been implemented and outcomes are assessed.

D. Develop the expected outcome with the client: Establishing expected outcomes is part of the planning phase. It follows assessment and involves collaboration with the client to determine realistic and measurable goals.

A. Mood B. Age C. Posture D. Gait

Correct Answer is A

Explanation

A. Mood: Behavioral assessment during the general survey involves observing the client’s affect, emotional state, and overall behavior. Evaluating mood helps the nurse understand how the client is coping, their level of emotional stability, and any signs of anxiety, depression, or distress. It provides insight into psychological and emotional well-being, which is essential for holistic care planning.

B. Age: Age is a component of the general survey that falls under physical characteristics rather than behavior. It helps establish baseline expectations for growth, development, and age-appropriate functioning, but it does not provide information about the client’s emotional state or behavior.

C. Posture: Posture is part of the physical appearance assessment within the general survey. It provides information about musculoskeletal health, possible pain, or functional limitations but does not reflect the client’s behavioral or emotional status.

D. Gait: Gait assessment evaluates how a client moves, including balance, coordination, and mobility. While it offers important physical and neurological information, it does not give direct insight into the client’s mood, affect, or behavioral patterns.

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The nurse is monitoring for risk for injuries identified in the healthcare environment. Which unsafe healthcare environment finding(s) will require action from the nurse? Select all that apply

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is A

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