d.Adolescent: drug and alcohol consumption;
motor vehicle crashes
e.Adult: spousal abuse; using alcohol to relieve
stress
f. Older adult: motor impairment; elder abuse
2.Sample answers:
a.Developmental considerations: A teenager who
drinks and drives is at risk for accidents; an
adult who is under stress at work is at risk for
drug or alcohol abuse.
b.Lifestyle: A person who lives in a high-crime
neighborhood is at risk for violence; a person
who has a dangerous job is at risk for accidents.
c. Limitation in mobility: An older patient with
an unsteady gait is at risk for falls; recent
surgery or prolonged illness can temporarily
affect mobility.
d.Limitation in sensory perception: Visual
changes may cause a person to stumble, lose
balance, and fall; a hearing deficit interferes
with normal communication and may result in
a patient who is insensitive to alarms, horns,
sirens, and so on.
e.Limitation in knowledge: A mother who does
not know how to childproof her home puts her
toddler at risk for accidents; an elderly person
who does not know how to use her walker is at
risk for falls.
f. Limitation in ability to communicate: Fatigue
or stress, certain medications, aphasia, and lan-
guage barriers are factors that can affect
personal interchange and compromise the
patient’s ability to express urgent safety
concerns.
g.Limitation in health status: A patient
recovering from a stroke may have muscle
impairment; many patients who fall also have a
primary or secondary diagnosis of cardiovascu-
lar disease.
h.Limitation in psychosocial state: Depression
may result in confusion and disorientation,
accompanied by reduced awareness of environ-
mental hazards; social isolation may be respon-
sible for a reduced level of concentration.- a.Nursing history: The nurse must be alert for any
history of falls because a person with a history
of falling is likely to fall again. Assistive devices
should be noted. A history of drug or alcohol
abuse should also be noted.
b.Physical assessment: Nurses need to assess the
patient’s mobility status, ability to
communicate, level of awareness or orientation,
and sensory perception.
c. Accident-prone behavior: Some people seem to
be more likely than others to have accidents.
d.The environment: The nurse must assess every
setting in which the patient is at risk for injury,
including the home, community, and
healthcare agency.
4.Sample answers:
a.Age older than 65 years
b.Documented history of falls
c. Slowed reaction time
d.Disorientation or confusion
5.Sample answers:
The mother should be informed about safety for
toddlers, and a plan should be devised to help her
childproof her home. The plan should include
the installation of cabinet locks; electrical outlet
covers; moving medications, cleaners, poisonous
plants, and so on to higher levels; and keeping
small or sharp objects out of reach.
6.Sample answers:
a.Do your children’s toys have small or loose parts?
b.Have you ever left your infant in the bathtub to
answer the phone?
c. Do you have soft pillows or thick blankets in
your infant’s crib?- a.Risk for Injury related to refusal to use child
safety seat
b.Risk for Poisoning related to reduced vision
c. Risk for Aspiration or Trauma (burns) related to
child left unattended in bathtub
d.Risk for Trauma related to history of previous
falls
e.Impaired Home Maintenance related to insuffi-
cient finances - a.Screening programs for vision and hearing
b.Fire prevention programs
c. Drug and alcohol prevention programs
9.Sample answers:
a.Impaired circulation
b.Pressure ulcers and diminished bone mass
c. Fractures
d.Altered nutrition and hydration
e.Incontinence
10.Documentation should include alternative strate-
gies that were ineffective, the reason for restraining
the patient, the type of restraint and time it was
applied, pertinent nursing assessments, and regular
intervals when restraints were removed.
11.The nurse completes the safety event report imme-
diately after an accident and is responsible for
recording the occurrence of the accident and its
effect on the patient in the medical record. The
report should objectively describe the circumstances
of the accident and provide details concerning the
patient’s response and the examination and treat-
ment of the patient after the event.
12.Have the patient sit in a straight-backed chair.
Observe his posture while seated. Instruct the
patient to stand. Assess if he can stand in one fluid
motion or needs the use of his hands to push up
to a standing position. Does he need multiple
attempts to stand? Once standing, ask the patient
to keep his eyes open and stand as still as possible.
Then ask him to close his eyes and observe his
stability with eyes closed. Ask him to open his eyes
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