2100 Test 1 Folder - All flashcards combined

A registered nurse has had her license suspended after being convicted of being impaired at work. What governing body has the authority to revoke or suspend a nurse's license? a) The National League for Nursing b) The Supreme Court c) The employing healthcare institution d) The State Board of Nurse Examiners

d) The State Board of Nurse Examiners The State Board of Nurse Examiners in the United States may revoke or suspend a nurse's license or registration for drug or alcohol abuse, which is the most common reason.

The nurse provides care for a client who was placed in a halo brace within the last 24 hours because of a spinal cord injury. Which of the following is the first priority of the nurse? a. Loosen connections on the vest to observe the skin. b. Ask how the client is able to reposition in bed. c. Encourage active range of motion to lower extremities. d. Examine the pin sites.

d. The nurse would want to observe pin sites for redness, edema, and drainage, and would want to assure that the vest fits snugly. Following the nursing process, data collection would precede implementation of the actions in the other choices.

Which action may a nurse on the orthopedic unit safely delegate to a licensed practical nurse (LPN)? obtaining vital signs during blood administration taking a telephone order for pain medications for a postoperative client teaching a client receiving warfarin about follow-up care assessing the hip wound during a dry sterile dressing change

obtaining vital signs during blood administration o The nurse may safely delegate obtaining vital signs during blood administration to the LPN. Teaching the client taking warfarin about follow-up care, assessing a hip wound, and taking a telephone order are actions that must be taken by the registered nurse because they aren't within the scope of LPN practice.

Incomplete SCI Syndrome caused by hyperextension of the neck (falls and MVAs)

Central Cord Syndrome

A nurse has been asked to chair an action team tasked with prioritizing a list of possible new equipment purchases. Which statements, made by this nurse, will help the team be most effective? Select all that apply. "Our goal is to prioritize this list of potential equipment purchases, offering rationale for our choices." "Once we have completed the list and rationale, I will compile our recommendations for us all to sign before submission." "I am willing to prioritize the list if someone else will write the rationale." "Before our next meeting, each of us will ask the nurses on the unit what their priority purchase would be." "When I got this assignment, they said something about deciding what equipment to purchase next year."

"Our goal is to prioritize this list of potential equipment purchases, offering rationale for our choices." "Once we have completed the list and rationale, I will compile our recommendations for us all to sign before submission." "Before our next meeting, each of us will ask the nurses on the unit what their priority purchase would be." o The most important component of team structure is to have a common goal. The goal of this group is to list potential equipment purchases with rationale. The second-most important component of team structure is to have clear roles and responsibilities. The direction by the nurse for the members to query nurses on each unit is an example of establishing clear roles and responsibilities. Teams also should hold themselves mutually accountable for achieving the goal, such as by having all the team members sign the recommendation. The work should be done by the team, not by just one or two members, as in the option about one nurse prioritizing the list and another writing rationale. Clarity and specificity are important in communicating the purpose of the team, both of which are lacking in the statement, "they said something about deciding what equipment to purchase next year."

Which nurse leader most clearly exemplifies transformational leadership? A leader who is dynamic and inspiring and promotes change by the power of the leader's convictions A leader who prioritizes the fact that every member of the team is considered valuable and equal A leader who is careful to thoughtfully assess the issues and priorities surrounding a problem prior to acting A leader who prioritizes the delegation of leadership to the individual members of the group

A leader who is dynamic and inspiring and promotes change by the power of the leader's convictions o Transformational leaders can create revolutionary change. They are often described as charismatic, and they are unique in their ability to inspire and motivate others. A careful examination of contextual factors is associated with situational leadership. Delegation to group members and an emphasis on equality are typical of laissez-faire and democratic leadership styles, respectively.

The nurse-manager of an outpatient facility isn't satisfied with discharge planning policies and procedures. Knowing other managers at similar facilities regarded as the "best" in the country, which steps should the nurse-manager take as part of a continuous quality-improvement process? Contact the nurse-managers at the best facilities and compare their discharge planning policies and procedures with those of her facility. Ask the nurse-managers at the best facilities for their policies and procedures so she can adopt them. Ask her staff nurses to investigate discharge policies and procedures at other outpatient facilities and recommend changes. Ask the staff nurses to form a task force to review and revise discharge policies and procedures.

Contact the nurse-managers at the best facilities and compare their discharge planning policies and procedures with those of her facility. o Benchmarking is a good approach for the nurse-manager to take. Benchmarking is the process of comparing an organization's delivery of client care practices in one organization to those in the best health care organizations. Because the nurse-manager already has contacts at the best facilities, she's the most appropriate person to obtain the necessary information. The nurse-manager, however, shouldn't automatically change her policies and procedures to match those of the best facilities. Instead, she should evaluate the policies to determine which ones might be implemented at her facility. Then she and her staff should make appropriate recommendations for change. Asking her staff to form a task force is a good idea, but benchmarking saves time and effort and enables the nurse-manager to obtain information from excellent resources.

The charge nurse is unable to replace a registered nurse for a shift on an acute medical unit. The staffing department states they are able to send an additional unlicensed assistive personnel (UAP) to assist. What priority action would the charge nurse take in this situation? Notify the local nursing regulating body about the unsafe working conditions at the facility. Call charge nurses on other units to request a registered nurse come assist on the unit. Refuse to create the client assignment and tell management that a nurse must be found. Create the client assignment by considering available staff's skill level and client needs.

Create the client assignment by considering available staff's skill level and client needs. o When working with less than an ideal number of registered nurses for a given number of clients, the charge nurse's first priority is to ensure safe distribution of client needs among the available staff members. The charge nurse's primary duty is to the safety of the clients. If there were serious impediments to safely adjusting the workload, it may be reasonable to voice this concern to the management, but the priority is to attempt to create the safe client assignment within the current staffing realities. The nurse should not attempt to arrange for staffing independently by calling other charge nurses as this is outside the role and responsibilities and may create safety concerns on other units. If the working conditions are considered unsafe, this could be a matter to be brought forward to a regulating body. However, in the moment, the charge nurse's priority is to attempt to distribute the clients' care in a safe manner.

The nurse manager on an orthopedic unit has determined that the nurses are not keeping the nursing diagnoses up-to-date on client care plans and, in turn, are not using the plan of care. What is a feasible approach to correcting this problem? Provide an in-service on interviewing and physical assessment skills; discuss the importance of these skills with the staff. Delegate the updating of nursing diagnoses for all clients on the unit to one nurse for each shift. Request that a staff development nurse instruct the nurses on concept mapping to use instead of care planning. Develop a process for periodic review of care plans that focuses on deleting and updating the nursing diagnoses.

Develop a process for periodic review of care plans that focuses on deleting and updating the nursing diagnoses. o Upon recognizing that the nursing diagnoses are not up-to-date, an effective approach by the nurse manager is to establish a process for periodic review of the plan of care. This review process will require deletion of nursing diagnoses that have been resolved and, conversely, adding new diagnoses as needed. Implementing concept mapping will not correct the problem of poorly updated nursing diagnoses, as concept mapping requires the identification of nursing diagnoses. Developing interviewing and assessment skills is an important component of the assessment phase of the nursing process. Also, one nurse should not be responsible for updating nursing diagnoses for all client care plans on the unit.

The nurse is caring for an obese client who needs to be turned every 2 hours. Which action by this nurse is an example of reflection-for-action? During the first attempt to turn the client, the nurse realizes the need for assistance and calls the front desk for help. Reflecting on prior experience and best practice, the nurse includes assistance with turning in the client's plan of care. The nurse decides to turn the client every 4 hours because everyone is too busy to help. After turning the client alone, the nurse realizes that the nurse should have insisted on having help.

Reflecting on prior experience and best practice, the nurse includes assistance with turning in the client's plan of care. o There are three types of reflection as defined by Schon: reflection-in-action, reflection-on-action, and reflection-for-action. Reflection-for-action is the desired outcome of the first two types and helps the person to think about how future actions might change as a result of the reflection. When the nurse realizes the need for help turning the client when first attempting to turn the client, this is reflection-in-action. When reflecting whether everyone is using appropriate resources, this is reflection-on-action. When adapting the client's plan of care based on these other reflections, this is reflection-for-action. Turning an obese client without assistance is unsafe and resources should be used. The client's outcomes should not be jeopardized by altering the plan of care due to the time constraints of staffing.

The nurse-manager of a 20-bed coronary care unit is not on duty when a staff nurse makes a serious medication error that results in a client's overdose. The client nearly dies. Which statement accurately reflects the accountability of the nurse-manager? Although the nurse-manager is off duty and not responsible for what happened, the nursing supervisor would call the nurse-manager only if time permits. The nurse-manager would receive a call at home from the on-duty nursing supervisor, apprising the nurse-manager of the problem as soon as possible. Because the nurse-manager is off duty and not accountable for incidents that occur in their absence, the nurse-manager need not be notified. The nurse-manager only needs to be informed of the incident when the nurse-manager reports to work on the next scheduled day.

The nurse-manager would receive a call at home from the on-duty nursing supervisor, apprising the nurse-manager of the problem as soon as possible. o The nurse-manager is accountable for what happens on the unit 24 hours per day, 7 days per week. If a serious problem occurs, the nurse-manager should be notified as soon as possible. None of the other choices accurately reflect the nurse--manager's accountability in this situation.

A charge nurse on the orthopedic unit functions to promote teamwork and to help the unit run smoothly. Which action should the charge nurse reconsider in order to promote teamwork? coordinating admissions and discharges to even the workload asking the nursing assistant to pick up medications from the pharmacy directing two nurses to cover a third nurse's clients while the nurse transfers a client to the intensive care unit assisting the nurse to schedule Doppler ultrasonography for a client without discussing it with the physical therapist

assisting the nurse to schedule Doppler ultrasonography for a client without discussing it with the physical therapist o Scheduling Doppler ultrasonography without first coordinating scheduling with the physical therapist doesn't promote teamwork. This lack of coordination may cause the client to miss a physical therapy session. Coordinating admissions and discharges to even the workload, having nurses cover for each other during client transfers, and delegating tasks to nursing assistants as appropriate promote teamwork.

Areflexia occurs when there is...

A loss of sympathetic reflex activity below the level of injury within 30 to 60 minutes of a spinal injury.

How is a paralytic illeus treated in SCI patients?

A nasogastric tube is often required

4. The nurse is caring for a patient with increased intracranial pressure (ICP) caused by a traumatic brain injury. Which of the following clinical manifestations would suggest that the patient may be experiencing increased brain compression causing brain stem damage? A) Hyperthermia B) Tachycardia C) Hypertension D) Bradypnea

Ans: A Feedback: Signs of increasing ICP include slowing of the heart rate (bradycardia), increasing systolic BP, and widening pulse pressure. As brain compression increases, respirations become rapid, BP may decrease, and the pulse slows further. A rapid rise in body temperature is regarded as unfavorable. Hyperthermia increases the metabolic demands of the brain and may indicate brain stem damage.

Incomplete SCI syndrome with: Paraplegia below the level of injury Quadraplegia for injuries higher than C7 Bilateral loss of pain and temperature Preservation of proprioception and vibratory senses below the level of injury

Anterior Cord Syndrome

What would you know is an acute emergency and is seen in clients with a cervical or high thoracic spinal cord injury after the spinal shock subsides?

Autonomic Dysreflexia

For a patient with an SCI, why is it beneficial to administer oxygen to maintain a high partial pressure of oxygen (PaO2)?

Because hypoxemia can create or worsen a neurologic deficit of the spinal cord.

The nurse fails to contact the physician regarding a client who had an open-reduction internal fixation of the tibia and has experienced increasing leg pain (unrelieved by pain medication) for the past 4 hours. Which element of liability has been violated? a) Duty b) Damages c) Causation d) Breach of duty

Breach of duty Explanation: Failure to contact the physician and report the client's condition does not meet the expected standard of care and is a breach of duty. Duty refers to an obligation to use due care and is defined by the standard of care appropriate for the nurse-client relationship. Causation shows that the failure to meet the standard of care actually caused injury. Damages are the actual harm or injury to the client.

Incomplete SCI Syndrome caused by hemisection of the spinal cord (gunshot, knife)

Brown-Sequard Syndrome

Incomplete SCI syndrome with: Motor paralysis, loss of proprioception, and vibratory sense below the level of injury on the same side as the injury Loss of pain and temperature sensation below the level of injury on the opposite side of the injury

Brown-Sequard Syndrome

Injuries above what level requires immediate intubation and mechanical ventilation?

C4

Incomplete SCI syndrome located at the L1 level

Conus medullaris syndrome

Paraplegia Occurs with...

Injuries at the thoracic level

The student nurse tells her family about a client with AIDS that she cared for in clinical yesterday. Which tort has the student committed? a) Assault b) Invasion of privacy c) Slander d) Fraud

Invasion of privacy Explanation: Invasion of privacy involves a breach of keeping client information confidential. Slander is oral defamation of character. Assault is a threat or attempt to make bodily contact with another person without that person's consent.

A client newly diagnosed with congestive heart failure has a prescription for digoxin (Lanoxin). The nurse counts the heart rate before administration of the medication and obtains a heart rate of 51 beats per minute. Which action by the nurse demonstrates adherence to the standards of nursing care? a) Nurse administered the medication and reassessed the client in 30 minutes b) Nurse withheld the medication, retook the heart rate, and gave it at a later time c) Nurse administered the medication after reviewing the client's serum potassium level d) Nurse withheld the medication and notified the health care practitioner

Nurse withheld the medication and notified the health care practitioner Explanation: Nurses are responsible for following the standards of care for their particular work area. A reasonably prudent nurse would withhold the medication and notify the health care practitioner. All other options put the client's safety at risk and would not be done by a reasonably prudent nurse.

A registered nurse has had her license suspended after being convicted of being impaired at work. What governing body has the authority to revoke or suspend a nurse's license? a) The National League for Nursing b) The Supreme Court c) The State Board of Nurse Examiners d) The employing health care institution

The State Board of Nurse Examiners Explanation: The State Board of Nurse Examiners in the United States may revoke or suspend a nurse's license or registration for drug or alcohol abuse.

During the orientation to the hospital, the staff development educator discusses unit and institutional-based policies. What is the source of the practice rules that result in unit and institutional-based policies? a) Healthcare institution b) Federal legislation c) State legislation d) Board of nursing

a) Healthcare institution The healthcare institution determines the unit and institutional policies. These policies may vary from institution to institution. Such policies may include clinical procedures, policies specific to the institution, and personnel and employment policies.

38. A patient with spinal cord injury is ready to be discharged home. A family member asks the nurse to review potential complications one more time. What are the potential complications that should be monitored for in this patient? Select all that apply. A) Orthostatic hypotension B) Autonomic dysreflexia C) DVT D) Salt-wasting syndrome E) Increased ICP

ans: A, B, C Feedback: For a spinal cord-injured patient, based on the assessment data, potential complications that may develop include DVT, orthostatic hypotension, and autonomic dysreflexia. Salt-wasting syndrome or increased ICP are not typical complications following the immediate recovery period.

28. The school nurse is giving a presentation on preventing spinal cord injuries (SCI). What should the nurse identify as prominent risk factors for SCI? Select all that apply. A) Young age B) Frequent travel C) African American race D) Male gender E) Alcohol or drug use

ans: A, D, E Feedback: The predominant risk factors for SCI include young age, male gender, and alcohol and drug use. Ethnicity and travel are not risk factors.

The family members of a client with a spinal cord injury tell the nurse that the client becomes angry whenever someone tries to help or participate in care. The nurse's best response is to: a. Tell the client the family will not visit anymore. b. Assist the family to understand the source of the client's anger. c. Ask the client to stop acting out with the family. d. Ask the family to refrain from giving care.

b. The nurse helps the family to understand and acknowledge the client's anger. The family would then make the choice about whether or not to continue to participate in the client's care. Asking the client to stop the anger is not reasonable. The client is grieving a significant loss and needs to be allowed to work through the issues. Telling the client that the family will not visit is threatening and inappropriate.

Which process evaluates and recognizes educational programs as having met certain standards? a) licensure b) credentialing c) accreditation d) certification

c) accreditation Accreditation is the process by which an educational program is evaluated and recognized as having met certain standards. Credentialing refers to ways in which professional competence is ensured and maintained. Licensure is the process by which a state determines that a candidate meets certain minimum requirements to practice in the profession and grants the license to do so. Certification is the process by which a person who has met certain criteria established by a nongovernmental association is granted recognition in a specified practice area.

The extent of injury to spinal neurological tissue is best identified by: a. clinical exam b. CT cord scan c. plain spinal x-rays d. MRI

d. MRI

A nurse is caring for a client who experienced a cervical spine injury 24 hours ago. Which of the following types of prescribed medications should the nurse clarify with the provider. a. glucocorticoids b. plasma expanders c. H2 antagonists d. muscle relaxants

d. The client will still be in spinal shock 24 hours following the injury. The client will not experience muscle spasms until after the spinal shock as resolved, making muscle relaxants unnecessary at this time. All other medications are appropriate

A nurse observes another nurse place an unused dose of narcotics in their pocket. If caught, the nurse could be charged with which type of crime? a) misdemeanor b) felony c) tort d) negligence

felony Explanation: A felony is a serious criminal offense, and includes actions such as stealing narcotics, murder, falsifying medical records, and insurance fraud. A misdemeanor is a minor criminal offense; a tort is a lawsuit in which a plaintiff charges that a defendant committed a deliberately aggressive act. Negligence is harm that results because a person did not act reasonably.

What is the priority nursing intervention for the management of autonomy hyperreflexia?

immediately place patient in an upright position with feet dangling to decrease BP

A nurse is called to a deposition for a malpractice charge that has resulted in the death of a client. As the chart is reviewed, the prosecuting attorney questions the nurse about several defaming comments written in the medical record about the client. What charges can be filed against the nurse due to these comments? a) malpractice b) negligence c) libel d) slander

libel Explanation: Libel is damaging statements written and read by others. Since there were defaming comments written in the chart, libel charges could be appropriate. Malpractice, slander, and negligence are not charges in this scenario.

An alert and oriented older adult female with metastatic lung cancer is admitted to the medical-surgical unit for treatment of heart failure. She was given 80 mg of furosemide in the emergency department. The nurse is instructing the unlicensed assistive personnel (UAP) to implement a nursing plan to manage potential incontinence. Which instruction will be most effective for this client? prescribing adult diapers for the client so she will not have to worry about incontinence requesting an indwelling urinary catheter to avoid incontinence placing a commode at the bedside and instructing the client in its use padding the bed with extra absorbent linens

placing a commode at the bedside and instructing the client in its use o A bedside commode should be near the client for easy, safe access. Measurement of urine output is also important in a client with heart failure. Putting diapers on an alert and oriented individual would be demeaning and inappropriate. Indwelling catheters are associated with increased risk of infection and are not a solution to possible incontinence. There is no reason to think that the client would not be able to use the bedside commode.

An RN is working on a medical-surgical unit with a licensed practical/vocational nurse (LPN/LVN). Which action by the RN is considered negligent if injury results from this action? Asking the LPN/LVN to teach a new diabetic client how to administer insulin Obtaining vital signs on a newly admitted client Calling the health care provider about abnormal lab results Delegating oral medication administration to the LPN/LVN

Asking the LPN/LVN to teach a new diabetic client how to administer insulin o Negligence is harm that results because a person did not act reasonably. As nurses perform the role of delegators, they must know which tasks are legal and appropriate for particular health care providers to perform (scope of practice), as well as the policy for the facility at which they are employed. Teaching is not in the current scope of practice for a LPN/LVN, and thus the RN's delegation of this task to the LPN/LVN could be considered negligence. The other actions are within the scope of practice for a LPN/LVN.

Why is a nasogastric tube indicated in a paralytic illeus for SCI patients?

Relieves distention and to prevent vomiting and aspiration

What causes Autonomic Dysreflexia?

Spinal cord injuries above T6

A nurse is assessing a client for changes in the LOC using the Glasgow Coma Scale. The client opens his eyes when spoken to, speaks incoherently, and moves his extremities when pain is applied. Which of the following is the correct scoring by the nurse using the scale that indicates the client has a moderate head injury? a. E2+ V3 + M5 = 10 b. E3 + V4 + M4 = 11 c. E4 + V5 + M6 = 15 d. E2 + V2 + M4 = 8

b.

Administration of large doses of methylprednisolone can result in: choose two a. hypoglycemia b. hypothermia c. hyperglycemia d. gastric bleeding

c. hyperglycemia d. gastric bleeding

The initial suggested loading dose of IV methylprednisolone when attempting to minimize spinal injury dysfunction secondary to acute injury is? a. 5.4 mg/kg b. 10.8 mg/kg c. 20 mg/kg d. 30 mg/kg

d. 30 mg/kg over 1 hour 5.4 mg/kg per hour to continue over the next 23 hours

A nurse is caring for a client who has a C4 spinal cord injury. Which of the following should the nurse recognize the client as being at the greatest risk for? a. neurogenic shock b. paralytic ileus c. stress ulcer d. respiratory compromise

d. using the ACB priority-setting, the greatest risk to the client is respiratory compromise secondary to involvement of the phrenic nerve. Maintenance of an airway and provision of ventilatory support as needed is the priority intervention

In some cases, the act of providing nursing care in unexpected situations is covered by the Good Samaritan laws. Which nursing actions would most likely be covered by these laws? a) negligent acts performed in an emergency situation b) emergency care for a choking victim in a restaurant c) any emergency care where consent is given d) medical advice given to a neighbor regarding her child's rash

emergency care for a choking victim in a restaurant Explanation: Good Samaritan laws are designed to protect health practitioners when they give aid to people in emergency situations, such as providing emergency care to a choking victim in a restaurant. The other examples listed are not situations covered by the Good Samaritan law.

Which attributes should be characteristic of a nurse mentor? Select all that apply. Is an experienced, licensed professional Is supportive Is resourceful Is driven by financial reward Deconstructs health care networks Demonstrates leadership abilities Embraces disruptive conflict

Is an experienced, licensed professional Is supportive Is resourceful Demonstrates leadership abilities o Mentors should demonstrate characteristics that will help the less experienced person grow in the profession. Mentors should be supportive, resourceful, experienced, respectable, and trustworthy leaders. Mentors do not receive financial compensation for their effort as preceptors typically do. Mentors should not embrace conflict that is disruptive to tasks. Mentors should build and use health care networks, not deconstruct them.

A nurse leader on a unit allows the staff to make all decisions and direct themselves, including filling out the work schedule. The nurse leader is practicing which leadership style? Autocratic Laissez-faire Transformational Democratic

Laissez-faire o In laissez-faire leadership, also called nondirective leadership, the leader relinquishes power to the group, such that an outsider could not identify the leader in the group. The democratic leadership style is characterized by a sense of equality among the leader and other participants. The autocratic leader assumes complete control over the decisions and activities of the group. Transformational leaders create intellectually stimulating practice environments and challenge themselves and others to grow personally, to grow professionally, and to learn.

37. A patient who is being treated in the hospital for a spinal cord injury is advocating for the removal of his urinary catheter, stating that he wants to try to resume normal elimination. What principle should guide the care teams decision regarding this intervention? A) Urinary retention can have serious consequences in patients with SCIs. B) Urinary function is permanently lost following an SCI. C) Urinary catheters should not remain in place for more than 7 days. D) Overuse of urinary catheters can exacerbate nerve damage.

ans: A Feedback: Bladder distention, a major cause of autonomic dysreflexia, can also cause trauma. For this reason, removal of a urinary catheter must be considered with caution. Extended use of urinary catheterization is often necessary following SCI. The effect of a spinal cord lesion on urinary function depends on the level of the injury. Catheter use does not cause nerve damage, although it is a major risk factor for UTIs.

2. A patient is brought to the trauma center by ambulance after sustaining a high cervical spinal cord injury 1 hours ago. Endotracheal intubation has been deemed necessary and the nurse is preparing to assist. What nursing diagnosis should the nurse associate with this procedure? A) Risk for impaired skin integrity B) Risk for injury C) Risk for autonomic dysreflexia D) Risk for suffocation

Ans: B Feedback: If endotracheal intubation is necessary, extreme care is taken to avoid flexing or extending the patients neck, which can result in extension of a cervical injury. Intubation does not directly cause autonomic dysreflexia and the threat to skin integrity is a not a primary concern. Intubation does not carry the potential to cause suffocation.

The new nurse is evaluating the effectiveness of the assigned nurse mentor. Which characteristic should the new nurse recognize as being inappropriate for the nurse mentor to role model? Advising the new nurse to consult the nurse mentor before making decisions regarding client care Introducing the new nurse to members of the interdisciplinary team Providing daily feedback to the new nurse Encouraging the new nurse to enroll in continuing education courses

Encouraging the new nurse to enroll in continuing education courses o Effective mentors should provide feedback to the mentee, encourage opportunities for continued growth, and provide resources that will be supportive in the new role of nurse, including members of the interdisciplinary team. Effective mentors should promote confidence in the new nurse in the decision making process. Requiring the new nurse to report to the nurse mentor before making decisions can hinder the new nurse's confidence level.

35. The nurse caring for a patient with a spinal cord injury notes that the patient is exhibiting early signs and symptoms of disuse syndrome. Which of the following is the most appropriate nursing action? A) Limit the amount of assistance provided with ADLs. B) Collaborate with the physical therapist and immobilize the patients extremities temporarily. C) Increase the frequency of ROM exercises. D) Educate the patient about the importance of frequent position changes.

ans: C Feedback: To prevent disuse syndrome, ROM exercises must be provided at least four times a day, and care is taken to stretch the Achilles tendon with exercises. The patient is repositioned frequently and is maintained in proper body alignment whether in bed or in a wheelchair. The patient must be repositioned by caregivers, not just taught about repositioning. It is inappropriate to limit assistance for the sole purpose of preventing disuse syndrome.

A new graduate nurse demonstrates understanding that developing and maintaining competency is crucial to giving adequate and safe care to all psychiatric clients. To whom would the new graduate assign this responsibility for maintaining this standard of professional performance? The graduate nurse The facility where the graduate now works The American Nurses Association The nursing school from which the student graduated

The graduate nurse o Developing and maintaining competency is the responsibility of the professional psychiatric-mental health nurse.

Which statement by a registered nurse (RN) represents appropriate delegation to a nursing assistant? "Check the infusion rate." "Dispose of the disconnected IV set." "Discontinue the IV solution." "Inspect the site for thrombophlebitis."

"Dispose of the disconnected IV set." o Disposing of a disconnected IV set is a task that is within the scope of practice of a nursing assistant. Discontinuing an IV solution, inspecting an IV site for thrombophlebitis, and checking the IV infusion rate are not within the scope of practice of a nursing assistant and should be performed by the RN.

11. A patient who suffered a spinal cord injury is experiencing an exaggerated autonomic response. What aspect of the patients current health status is most likely to have precipitated this event? A) The patient received a blood transfusion. B) The patients analgesia regimen was recent changed. C) The patient was not repositioned during the night shift. D) The patients urinary catheter became occluded.

: D Feedback: A distended bladder is the most common cause of autonomic dysreflexia. Infrequent positioning is a less likely cause, although pressure ulcers or tactile stimulation can cause it. Changes in mediations or blood transfusions are unlikely causes.

33. A nurse on the neurologic unit is providing care for a patient who has spinal cord injury at the level of C4. When planning the patients care, what aspect of the patients neurologic and functional status should the nurse consider? A) The patient will be unable to use a wheelchair. B) The patient will be unable to swallow food. C) The patient will be continent of urine, but incontinent of bowel. D) The patient will require full assistance for all aspects of elimination.

: D Feedback: Patients with a lesion at C4 are fully dependent for elimination. The patient is dependent for feeding, but is able to swallow. The patient will be capable of using an electric wheelchair.

A medical surgical client is in the radiology department. The client's cousin arrives on the medical surgical unit and asks to speak with the nurse caring for his cousin. The visitor asks the nurse to provide a brief outline of the client's illness. Which response, if given by the nurse, would demonstrate application of legal safeguard in her practice? a) "Do you have any identification proving you are related to the client?" b) "I cannot give you that information due to client confidentiality." c) "I will call the client and ask his permission." d) "I'm busy right now, but can talk later."

"I cannot give you that information due to client confidentiality." Explanation: Sharing a client's information without his or her consent is an invasion of privacy. The nurse cannot give out the information even if the client proves a relationship or at a later time without the client's consent. It is inappropriate to call the client to ask for permission.

What type of airway would be used?

-Endotracheal tube -Provides an airway from the nose or mouth to an area above the mainstem bronchi

Autonomic Dysreflexia Definition

-Exaggerated sympathetic nervous system response -A Hypertensive emergency

A staffing agency is assigning a licensed practical/vocational nurse (LPN/VN) to cover a shift on a pediatric unit. Because the unit manager is unfamiliar with the nurse's skill level, what assignment is best for the LPN/VN? 10-year-old child who had a tonsillectomy that morning 9-year-old child with Legg-Calve'-Perthes disease 8-year-old child admitted that morning with suspected meningitis 9-year-old child receiving subcutaneous insulin for diabetes mellitus

9-year-old child receiving subcutaneous insulin for diabetes mellitus o The unit manager should assign the LPN/VN to the child with diabetes mellitus. Because the client is receiving subcutaneous insulin rather than IV insulin, the diabetes is likely stable. Meningitis is an acute condition with the potential to progress into respiratory depression and seizures; this child will require frequent nursing assessments. The child who had a tonsillectomy remains at risk for hemorrhage during the first 24 hours following surgery. Legg-Calve'-Perthes disease is associated with impaired circulation to the femoral capital epiphysis; the child with this condition requires aggressive monitoring.

Which of the following is an example of certification? a) A nurse who demonstrates advanced expertise in a content area of nursing through special testing. b) An education program that meets standards of the National League for Nursing. c) A graduate of a nursing education program who passes NCLEX-RN. d) A hospital meets the standards of the Joint Commission.

A nurse who demonstrates advanced expertise in a content area of nursing through special testing. Explanation: Certification is a voluntary process where a person who has met criteria established by a nongovernmental association is granted special recognition in a specified practice area. Licensure is granted by the state to a graduate of a nursing education program who passes NCLEX-RN. Accreditation is a voluntary process by which a nursing education program is recognized as having met certain standards by the National League for Nursing Accrediting Commission and/or the American Association of Colleges of Nursing. The Joint Commission can also accredit healthcare agencies

A student nurse is assisting an elderly patient to ambulate following hip replacement surgery, and the patient falls and reinjures the hip. Who is potentially responsible for the injury to this patient? a) The nurse instructor b) The student nurse c) The hospital d) All of the above

All of the above Explanation: As a student nurse, you are responsible for your own acts, including any negligence that may result in patient injury. A hospital may also be held liable for the negligence of a student nurse enrolled in a hospital-controlled program because the student is considered an employee of the hospital. The status of students enrolled in college and university programs is less clear, as is the liability of the educational institution in which they are enrolled and the health care agency offering a site for clinical practice. Nursing instructors may share responsibility for damages in the event of patient injury if an assignment called for clinical skills beyond a student's competency or the instructor failed to provide reasonable and prudent clinical supervision.

22. A patient is admitted to the neurologic ICU with a suspected diffuse axonal injury. What would be the primary neuroimaging diagnostic tool used on this patient to evaluate the brain structure? A) MRI B) PET scan C) X-ray D) Ultrasound

Ans: A Feedback: CT and MRI scans, the primary neuroimaging diagnostic tools, are useful in evaluating the brain structure. Ultrasound would not show the brain nor would an x-ray. A PET scan shows brain function, not brain structure.

Incomplete SCI syndrome with: Motor loss of the upper extremities Bladder dysfunction Sensory loss below the level of injury

Central cord syndrome

A client states that his recent fall was caused by the fact that his scheduled antihypertensive medications were mistakenly administered by two different nurses, an event that is disputed by both of the nurses identified by the client. Which measure should the nurses prioritize when anticipating that legal action may follow? a) Enlist support from nursing and non-nursing colleagues from the unit. b) Document the client's claims and the events surrounding the alleged incident. c) Consult with practice advisors from the state board of nursing. d) Consult with the hospital's legal department as soon as possible.

Document the client's claims and the events surrounding the alleged incident. Explanation: It is imperative for nurses to carefully and accurately document assessment findings and the nursing care that they provide, a fact that is especially salient when legal action is anticipated. This thorough and accurate assessment should precede consultation with the legal department, the state board of nursing, and colleagues.

A client informs the nurse that he wants to discontinue his treatment and go home. Later, the nurse finds the client dressed to leave. Which action should the nurse take in this situation? a) Let the client go after signing a document stating he is going against medical advice. b) Call the physician and get his discharge paper signed. c) Restrain the client until his medical treatment is over. d) Warn the client that he may not be able to access health care again.

Let the client go after signing a document stating he is going against medical advice. Explanation: If a client wishes to go before his medical treatment is finished, he should sign a document indicating personal responsibility for leaving against medical advice. The nurse should not restrain the client, as it would make the nurse liable for legal action. The nurse may call the physician and get the discharge paper signed, but this is not appropriate. The nurse cannot warn the client that he will be denied health care in future, because it is his right to access the health care facility whenever he needs.

A client has a prescription for amoxicillin (Amoxil) 500 mg P.O. (by mouth) every 8 hours. The nurse administers the medication via the intravenous route. Based on the nurse's action, the client develops a pulmonary embolus, experiences respiratory distress, and is transferred to the intensive care unit. The client's family files a lawsuit against the facility and the nurse. While reviewing the case, which legal action has the nurse attorney identified that meets the criteria for the client's lawsuit? a) Assault b) Battery c) Malpractice d) Negligence

Malpractice Explanation: The facility and nurse could be charged with malpractice, which is failing to perform or performing an act that causes harm to a client. Administering the medication intravenously instead of orally as prescribed has caused harm to a client. Negligence is failing to perform care for a client. When a person threatens to touch a client without consent, it is assault, whereas battery is carrying out the implied threat (assault).

A physician is called to see a client with angina. During the visit the physician advises the nurse to decrease the atenolol to 12.5 mg. However, since the physician is late for another visit, she requests that the nurse write down the order for her. What should be the appropriate nursing action in this situation? a) The nurse should ask the physician to come back and write the order. b) The nurse should remind the physician later to write the work order. c) The nurse should inform the client of the change in medication. d) The nurse should write the order and implement it.

The nurse should ask the physician to come back and write the order. Explanation: The nurse should ask the physician to come back and write down the order. Nurses are discouraged from following any verbal orders, except in an emergency. The nurse should never write an order on a physician's behalf because this is a wrong practice. The client should be informed about the change of medications, but this is not an appropriate action. The nurse should not leave the work for a later time, because the nurse may forget it.

Tetraplegia Results when ...

There is a high cervical spine injury

Which is not true regarding Nurse Practice Acts? a) They describe what medications nurses can prescribe. b) They vary among states. c) They were established to describe legitimate nursing function. d) They define the boundaries of the functions of a nurse.

They describe what medications nurses can prescribe. Explanation: Prescribing and dispensing medications are not legal practices for registered nurses, with the exception of nurses in advance practice roles.

If you wanted to find a list of the violations that can result in disciplinary actions against a nurse, you should read which of the following? a) Nurse Practice Act b) Code of Ethics for Nurses c) Nurses' Bill of Rights d) American Journal of Nursing

a) Nurse Practice Act Each stated has a Nurse Practice Act that protects the public by broadly defining the legal scope of nursing practice. Practicing beyond those limits makes you vulnerable to charges of violating the state Nurse Practice Act. Nurse Practice Acts list the violations that can result in disciplinary actions against a nurse and also serve to exclude untrained or unlicensed people from practicing nursing.

Nurse Practice Acts are examples of which type of laws? a) statutory laws b) common law c) constitutional laws d) administrative laws

a) statutory laws Nurse Practice Acts are statutory laws. Statutory laws must be in keeping with both the federal constitution and the state constitution.

The nurse in the emergency department is admitting a client who fell from a two-story roof while cleaning gutters 2 days ago. The client states that he is experiencing erectile dysfunction, which is why he decided to seek treatment. The nurse suspects that this client is experiencing which of the following? a. A sacral injury at the level of S3 b. A thoracic injury at the level of T6 c. A cervical spine injury d. A lumbar spine injury

a. An injury to the sacral spine at S2-S4 is likely to cause the male client to have erectile and ejaculation issues. Cervical spine injuries are fatal at C2-C4 and cause paralysis below C4. Thoracic injury symptoms range from loss of chest movement to loss of movement of bowel and bladder. Lumbar injuries can cause issues with movement and sensation of the lower extremities.

The nurse is planning to teach the client with SCI and intermittent NG suctioning about interventions to protect her integumentary system. The nurse should tell the client to: a. eat enough calories to maintain desired weight b. stay in cool environments to avoid sweating c. stay in warm environments to avoid chilling d. eat low-sodium foods to avoid edema

a. calories To decrease the rate of muscle atrophy and prevent skin breakdown and infection. The client with SCI does not have poikilothermy, the ability to adjust body temperature to the environment. The client should add additional clothes ore coverage below the level of transection in cool environments. The client does not sweat below the level of transection and should be sensitive to the possibility of overheating in hot climates. The client with intermittent NG suctioning is at risk for development of metabolic alkalosis and an electrolyte imbalance that leads to decreased tissue perfusion; therefore, the clients needs to increase NA and K, not decrease NA

When assessing the client with a cord transection above T5 for possible complications, which of the following should the nurse expect as least likely to occur? a. diarrhea b. paralytic ileus c. stress ulcers d. intra-abdomina bleeding

a. diarrhea constipation is more likely

Brown-Sequard Syndrome is characterized by: choose two a. motor loss on the same side as the injury b. motor loss on the opposite side as the injury c. sensory loss on the same side as the injury d. sensory loss on the opposite side as the injury

a. motor loss on same side d. sensory loss on the opposite side

A nurse is planning care for a client who suffered a spinal cord injury (SCI) involving a T12 fracture 1 week ago. The client has no muscle control of the lower limbs, bowel, or bladder. Which of the following should be the nurses's highest priority? a. prevention of further damage to the spinal cord b. prevention of contractors of the lower extremities c. prevention of skin breakdown of areas that lack sensation d. prevention of postural hypotension when placing the client in a wheelchair

a. the greatest risk to the client during the acute phase of a SCI is further damage tot he spinal cord Therefore, when planning care, the priority should be the prevention of further damage tot he spinal cord by administration of corticosteriods, minimizing movement of the client until spinal stabilization is accomplished through either traction or surgery, and adequate oxygenation of the client to decrease ischemia of the spinal cord.

A nurse is caring for a client post-lumbar puncture who reports a throbbing headache when sitting upright for meals. Which of the following are appropriate actions by the nurse? select all a. use the Glasgow Coma Scale b. assist the client to eat meals while laying flat in bed c. administer an opioid medication d. encourage client to increase fluid intake e. place client in a "cannonball" position

b. prone position c. opioid d. fluid a. GCS is used to assess LOC d. cannonball position is used for the LP

Two important clinical determinants of an incomplete spinal cord injury are: (choose two) a. shoulder shrug b. voluntary rectal sphincter tone c. sensation above the nipple line d. perirectal pain perception on needle stick

b. sphincter tone d. perirectal pain

A nurse is caring for a client with a spinal cord injury who reports a severe headache and is sweating profusely. Vital signs include BP of 220/110, with an apical HR of 54/min. Which of the following actions should the nurse take first? a. notify the provider b. sit the client upright in bed c. check the client's urinary catheter for a blockage d. administer antihypertensive medications

b. the greatest risk to the client is a CVA (stroke) secondary to elevated BP. The first action by the nurse is to elevate the head of the bed until the client is in an upright position. This will lower the blood pressure secondary to postural hypotension.

Which of the following aspects of nursing would be most likely defined by legislation at a state level? a) The process that nurses must follow when handling and administering medications. b) The criteria that patients must meet in order to qualify for Medicare or Medicaid. c) The differences in the scope of practice between registered nurses (RNs) and licensed practical nurses (LPNs). d) The criteria that a nurse must consider when delegating tasks to unlicensed care providers.

c) The differences in the scope of practice between registered nurses (RNs) and licensed practical nurses (LPNs). The scope of practice defines the parameters within which nurses provide care and is established by state legislation, most commonly in the form of a Nurse Practice Act. The criteria and due process for delegation in the clinical setting is addressed by a stated board of nursing. Qualification criteria for programs such as Medicare and Medicaid are established by federal legislation while the process for safe and appropriate medication administration is defined and monitored by a stated board of nursing.

Having recently completed a specialty nursing program in neonatal care, a nurse is now preparing to leave her current position on a medical unit and begin providing care in the hospital's neonatal intensive care unit (NICU). The nurse has completed which of the following processes of credentialing? a) accreditation b) licensure c) certification d) validation

c) certification The process of certification involves the attainment and validation of specialized nursing knowledge and skills. Certification is often necessary in order to ensure that the nursing care that is provided in specialized and high-acuity settings is safe and appropriate. Accreditation is the process by which an educational program, rather than an individual nurse, identifies that standards are being met. The process of licensure involves the determination that a nurse meets minimum requirements to practice, but not necessarily the specialized knowledge that is necessary for some care settings.Validation is not a specific aspect of the process of credentialing.

During the period of spinal shock, the nurse should expect the client's bladder function to be which of the following? a. spastic b. normal c. atonic d. uncontrolled

c. atonic Will continue to fill passively unless the client is catheterized. The bladder will not go into spasms or cause uncontrolled urination.

The client with a SCI asks the nurse why the dietician has recommended to decrease the total fail intake of calcium. Which of the following responses by the nurse would provide the most accurate information? a. Excessive intake of fairy products makes constipation more common b. Immobility increases calcium absorption from the intestine c. Lack of weight bearing causes demineralization of the long bones d. Dairy products likely will contribute to weight gain.

c. lack of weight bearing causes demineralization of the long bones causing kidney stones

Which of the following should the nurse use as the best method to assess for the development of DVT in a client with a SCI? a. homans' sign b. pain c. tenderness d. leg girth

d. leg girth Patient can't feel A, B, and C

Which situation is an example of battery that the nurse may experience while performing her duties at the health care facility? a) telling the client that he cannot leave the hospital b) witnessing a procedure done on a client without his consent c) taking the client's photographs without consent d) performing a surgical procedure without getting consent

performing a surgical procedure without getting consent Explanation: Performing a surgical procedure without the client's consent is an example of battery. To protect health care workers from being charged with battery, adult clients are asked to sign a general permission for care and treatment during admission, and additional written consent forms for tests, procedures, or surgery. Telling the client not to leave the hospital is a false imprisonment. Taking the client's photographs without his permission and witnessing a procedure done on him without consent is violation of the client's privacy.

A client is admitted to an acute care facility after having a stroke. The client will require a variety of healthcare services throughout the hospital stay as well as coordination of care prior to discharge. What referral would be a priority for overseeing the client's care? Physical therapy Dietary services Occupational therapy Case management

Case management o The person responsible for overseeing the client's care, usually an RN with a bachelor's or master's degree or another highly experienced health professional, is called the case manager. Physical therapy, occupational therapy, and dietary services are all important care disciplines but do not encompass all of the client's needs.

The charge nurse is unable to replace a registered nurse for a shift on an acute medical unit. The staffing department states they are able to send an additional unlicensed assistive personnel (UAP) to assist. What priority action would the charge nurse take in this situation? Create the client assignment by considering available staff's skill level and client needs. Refuse to create the client assignment and tell management that a nurse must be found. Notify the local nursing regulating body about the unsafe working conditions at the facility. Call charge nurses on other units to request a registered nurse come assist on the unit.

Create the client assignment by considering available staff's skill level and client needs. o When working with less than an ideal number of registered nurses for a given number of clients, the charge nurse's first priority is to ensure safe distribution of client needs among the available staff members. The charge nurse's primary duty is to the safety of the clients. If there were serious impediments to safely adjusting the workload, it may be reasonable to voice this concern to the management, but the priority is to attempt to create the safe client assignment within the current staffing realities. The nurse should not attempt to arrange for staffing independently by calling other charge nurses as this is outside the role and responsibilities and may create safety concerns on other units. If the working conditions are considered unsafe, this could be a matter to be brought forward to a regulating body. However, in the moment, the charge nurse's priority is to attempt to distribute the clients' care in a safe manner.

A registered nurse (RN) is caring for four clients on a medical-surgical unit. Which task is most appropriate for the nurse to delegate to the licensed practical nurse (LPN)? administering chemotherapy administering blood products administering intravenous push medication administering bedside blood glucose testing

administering bedside blood glucose testing o The LPN, under the nurse practice act (NPA), is permitted to administer testing for bedside blood glucose. The nurse must recognize the scope of practice of the delegate, and remember that client needs and activities delegated must be matched to skill level. The RN would not delegate administration of blood products, intravenous push medication, or chemotherapy to the LPN, as these tasks are not covered under the LPN's NPA.

29. The school nurse has been called to the football field where player is immobile on the field after landing awkwardly on his head during a play. While awaiting an ambulance, what action should the nurse perform? A) Ensure that the player is not moved. B) Obtain the players vital signs, if possible. C) Perform a rapid assessment of the players range of motion. D) Assess the players reflexes.

ans: A Feedback: At the scene of the injury, the patient must be immobilized on a spinal (back) board, with the head and neck maintained in a neutral position, to prevent an incomplete injury from becoming complete. This is a priority over determining the patients vital signs. It would be inappropriate to test ROM or reflexes.

1. The ED nurse is caring for a patient who has been brought in by ambulance after sustaining a fall at home. What physical assessment finding is suggestive of a basilar skull fracture? A) Epistaxis B) Periorbital edema C) Bruising over the mastoid D) Unilateral facial numbness

: C Feedback: An area of ecchymosis (bruising) may be seen over the mastoid (Battles sign) in a basilar skull fracture. Numbness, edema, and epistaxis are not directly associated with a basilar skull fracture.

32. A patient with a spinal cord injury has experienced several hypotensive episodes. How can the nurse best address the patients risk for orthostatic hypotension? A) Administer an IV bolus of normal saline prior to repositioning. B) Maintain bed rest until normal BP regulation returns. -1291 C) Monitor the patients BP before and during position changes. D) Allow the patient to initiate repositioning.

: C Feedback: To prevent hypotensive episodes, close monitoring of vital signs before and during position changes is essential. Prolonged bed rest carries numerous risks and it is not possible to provide a bolus before each position change. Following the patients lead may or may not help regulate BP.

24. An 82-year-old man is admitted for observation after a fall. Due to his age, the nurse knows that the patient is at increased risk for what complication of his injury? A) Hematoma B) Skull fracture C) Embolus D) Stroke

: A Feedback: Two major factors place older adults at increased risk for hematomas. First, the dura becomes more adherent to the skull with increasing age. Second, many older adults take aspirin and anticoagulants as part of routine management of chronic conditions. Because of these factors, the patients risk of a hematoma is likely greater than that of stroke, embolism, or skull fracture.

20. Following a spinal cord injury a patient is placed in halo traction. While performing pin site care, the nurse notes that one of the traction pins has become detached. The nurse would be correct in implementing what priority nursing action? A) Complete the pin site care to decrease risk of infection. B) Notify the neurosurgeon of the occurrence. C) Stabilize the head in a lateral position. D) Reattach the pin to prevent further head trauma.

: B Feedback: If one of the pins became detached, the head is stabilized in neutral position by one person while another notifies the neurosurgeon. Reattaching the pin as a nursing intervention would not be done due to risk of increased injury. Pin site care would not be a priority in this instance. Prevention of neurologic injury is the priority.

15. A patient is admitted to the neurologic ICU with a spinal cord injury. When assessing the patient the nurse notes there is a sudden depression of reflex activity in the spinal cord below the level of injury. What should the nurse suspect? A) Epidural hemorrhage B) Hypertensive emergency C) Spinal shock D) Hypovolemia

: C Feedback: In spinal shock, the reflexes are absent, BP and heart rate fall, and respiratory failure can occur. Hypovolemia, hemorrhage, and hypertension do not cause this sudden change in neurologic function.

12. A patient is admitted to the neurologic ICU with a spinal cord injury. In writing the patients care plan, the nurse specifies that contractures can best be prevented by what action? -1282 A) Repositioning the patient every 2 hours B) Initiating range-of-motion exercises (ROM) as soon as the patient initiates C) Initiating (ROM) exercises as soon as possible after the injury D) Performing ROM exercises once a day

: C Feedback: Passive ROM exercises should be implemented as soon as possible after injury. It would be inappropriate to wait for the patient to first initiate exercises. Toes, metatarsals, ankles, knees, and hips should be put through a full ROM at least four, and ideally five, times daily. Repositioning alone will not prevent contractures.

8. A patient with spinal cord injury has a nursing diagnosis of altered mobility and the nurse recognizes the increased the risk of deep vein thrombosis (DVT). Which of the following would be included as an appropriate nursing intervention to prevent a DVT from occurring? A) Placing the patient on a fluid restriction as ordered B) Applying thigh-high elastic stockings C) Administering an antifibrinolyic agent D) Assisting the patient with passive range of motion (PROM) exercises

: B Feedback: It is important to promote venous return to the heart and prevent venous stasis in a patient with altered mobility. Applying elastic stockings will aid in the prevention of a DVT. The patient should not be placed on fluid restriction because a dehydrated state will increase the risk of clotting throughout the body. Antifibrinolytic agents cause the blood to clot, which is absolutely contraindicated in this situation. PROM exercises are not an effective protection against the development of DVT.

6. The staff educator is precepting a nurse new to the critical care unit when a patient with a T2 spinal cord injury is admitted. The patient is soon exhibiting manifestations of neurogenic shock. In addition to monitoring the patient closely, what would be the nurses most appropriate action? A) Prepare to transfuse packed red blood cells. B) Prepare for interventions to increase the patients BP. C) Place the patient in the Trendelenberg position. D) Prepare an ice bath to lower core body temperature.

: B Feedback: Manifestations of neurogenic shock include decreased BP and heart rate. Cardiac markers would be expected to rise in cardiogenic shock. Transfusion, repositioning, and ice baths are not indicated interventions.

25. A neurologic flow chart is often used to document the care of a patient with a traumatic brain injury. At what point in the patients care should the nurse begin to use a neurologic flow chart? A) When the patients condition begins to deteriorate B) As soon as the initial assessment is made C) At the beginning of each shift D) When there is a clinically significant change in the patients condition -1288

: B Feedback: Neurologic parameters are assessed initially and as frequently as the patients condition requires. As soon as the initial assessment is made, the use of a neurologic flowchart is started and maintained. A new chart is not begun at the start of every shift.

10. A patient who has sustained a nondepressed skull fracture is admitted to the acute medical unit. Nursing care should include which of the following? A) Preparation for emergency craniotomy B) Watchful waiting and close monitoring C) Administration of inotropic drugs D) Fluid resuscitation

: B Feedback: Nondepressed skull fractures generally do not require surgical treatment; however, close observation of the patient is essential. A craniotomy would not likely be needed if the fracture is nondepressed. Even if treatment is warranted, it is unlikely to include inotropes or fluid resuscitation.

18. A nurse is reviewing the trend of a patients scores on the Glasgow Coma Scale (GCS). This allows the nurse to gauge what aspect of the patients status? A) Reflex activity B) Level of consciousness C) Cognitive ability D) Sensory involvement

: B Feedback: The Glasgow Coma Scale (GCS) examines three responses related to LOC: eye opening, best verbal response, and best motor response. -1285

40. A patient is admitted to the neurologic ICU with a C4 spinal cord injury. When writing the plan of care for this patient, which of the following nursing diagnoses would the nurse prioritize in the immediate care of this patient? A) Risk for impaired skin integrity related to immobility and sensory loss B) Impaired physical mobility related to loss of motor function C) Ineffective breathing patterns related to weakness of the intercostal muscles D) Urinary retention related to inability to void spontaneously

: C Feedback: A nursing diagnosis related to breathing pattern would be the priority for this patient. A C4 spinal cord injury will require ventilatory support, due to the diaphragm and intercostals being affected. The other nursing diagnoses would be used in the care plan, but not designated as a higher priority than ineffective breathing patterns.

22. A patient is admitted to the neurologic ICU with a suspected diffuse axonal injury. What would be the primary neuroimaging diagnostic tool used on this patient to evaluate the brain structure? A) MRI B) PET scan C) X-ray D) Ultrasound

: A Feedback: CT and MRI scans, the primary neuroimaging diagnostic tools, are useful in evaluating the brain structure. Ultrasound would not show the brain nor would an x-ray. A PET scan shows brain function, not brain structure.

A nurse completing admission paperwork asks the client about having an advanced directive. The client states, "I do not know, what is an advanced directive?" What is the nurse's best response? a) "It is a written document that identifies a person's preferences regarding which medical interventions to use in the event of a terminal condition." b) "It is a document created by you and your attorney naming a benificiary to handle your estate if you become terminally ill." c) "It is an agreement that authorizes the hospital to make decisions on your behalf, if you become incapacitated." d) "I will contanct the hospital social worker to come and discuss the development of an advance directive with you."

"It is a written document that identifies a person's preferences regarding which medical interventions to use in the event of a terminal condition." Explanation: An advance directive is a written statement identifying a competent person's preferences regarding which medical interventions to use in the event that the client can not make a decision for themselves concerning terminal care. The other responses are not correct.

Why are client with spinal trauma often given an artificial airway? Why do they need mechanical ventilation?

-To prevent hypoxemia, the client may need more oxygen than is available in the room air. -Mechanical ventilation provides a means to regulate the respiratory rate, volume of air, and percentage of oxygen when a client fails to breathe independently.

Predominant risk factors for SCI

-Young age (most between 16 and 30 years old) -Gender (80% of those living with SCI are male) -Alcohol/drug use

31. The nurse is planning the care of a patient with a T1 spinal cord injury. The nurse has identified the diagnosis of risk for impaired skin integrity. How can the nurse best address this risk? A) Change the patients position frequently. B) Provide a high-protein diet. C) Provide light massage at least daily. D) Teach the patient deep breathing and coughing exercises.

: A Feedback: Frequent position changes are among the best preventative measures against pressure ulcers. A high- protein diet can benefit wound healing, but does not necessarily prevent skin breakdown. Light massage and deep breathing do not protect or restore skin integrity.

17. A patient with a T2 injury is in spinal shock. The nurse will expect to observe what assessment finding? A) Absence of reflexes along with flaccid extremities B) Positive Babinskis reflex along with spastic extremities C) Hyperreflexia along with spastic extremities D) Spasticity of all four extremities

: A Feedback: During the period immediately following a spinal cord injury, spinal shock occurs. In spinal shock, all reflexes are absent and the extremities are flaccid. When spinal shock subsides, the patient demonstrates a positive Babinskis reflex, hyperreflexia, and spasticity of all four extremities.

What usually develops Immediately after a SCI?

A paralytic illeus

A client informs the nurse that he is leaving the health care facility because he is not satisfied with the treatment. The nurse knows that the client's treatment is incomplete and further testing and evaluations are scheduled. Which action by the nurse would be most appropriate to prevent false imprisonment? a) Restrain the client to prevent him from leaving. b) Tell the client that he will not be able to get access again. c) Ask the client to sign a release without medical approval. d) Call the physician to speed up the discharge process.

Ask the client to sign a release without medical approval. Explanation: If a client wants to leave the health care facility, the nurse should ask him to sign a release stating that he left without medical approval. The nurse cannot restrain the client because it amounts to false imprisonment. Calling the physician is not an appropriate measure. Telling the client that he may not be able to access the health care facility again is an inappropriate response because health care is a right and the client can access it whenever necessary.

Incomplete SCI syndrome with: Upper and lower motor neuron dynfunction Saddle anesthesia Lower extremity weakness Areflexic bladder and bowel

Conus medullaris syndrome

When a pt is in a cervical collar, what position should they be in until a spinal injury is ruled out?

Flat, except for logrolling as needed

A nurse is caring for a client who experienced a cervical spine injury 3 months ago. Which of the following types of bladder management methods should the nurse use for this client? a. condom catheter b. intermittent urinary cauterization c. Crede's method d. indwelling urinary catheter

a. a client who has a cervical spinal cord injury will also have an upper motor neuron injury, which is manifested by a spastic bladder. Because the bladder will empty on its own, a condom catheter is an appropriate method and it's noninvasive.

The nurse is planning care for a client with a spinal cord injury with paraplegia. The nurse selects the nursing diagnosis of risk for injury related to spasticity of the leg muscles. The nurse plans which of the following interventions? (Select all that apply.) a. Perform range of motion to the legs. b. Use padded restraints to immobilize the limbs. c. Do not give baclofen (Lioresal) unless client seizes. d. Remove potentially harmful objects near the spastic legs. e. Provide skin care to the affected limbs.

Perform range of motion to the legs. Remove potentially harmful objects near the spastic legs. Provide skin care to the affected limbs.

A central cord syndrome is characterized by: choose two a. disproportionately greater motor impairment of the upper extremities b. disproportionately greater motor impairment of the lower extremities c. variable sensory loss below the level of injury d. loss of positional sense below the level of injury

a. greater motor impairment of the upper ext. c. sensory loss below the level of injury

During the admission assessment of a female client age 40 years with a suspected mandibular fracture, the client discloses to the nurse that her injury came as a result of her husband hitting her. Which action should the nurse prioritize when responding to this disclosure? a) Reporting the abuse to the appropriate authorities b) Informing the client of her right to keep this information private c) Performing an assessment to confirm the client's statement d) Ensuring the client's statement is confirmed by another nurse

Reporting the abuse to the appropriate authorities Explanation: Nurses have a legal and ethical obligation to report cases of abuse. It would be inappropriate and likely unethical to require a third party witness to the statement or to withhold action pending assessment results. The nurse's obligation to report abuse legally supersedes the client's right to privacy

The nurse is caring for a client with a spinal cord injury who has very little interest in eating or drinking. The nurse plans to instruct the client about risks associated with inadequate intake of food and fluids including which of the following? a. Skin breakdown c. Headaches c. Diarrhea d. Contractures of the legs

a. The client who is taking in inadequate food is at risk for developing breaks in the skin and resulting infection. Headaches and contractures are not associated with poor nutrition. Constipation, not diarrhea, is a risk associated with decreased fluids.

A nurse witnesses a traffic accident and dresses the open wounds sustained by a child. Later, in the hospital, the child develops complications from an infection in the wound. The family holds the nurse responsible for the complications and attempts to file a lawsuit. Which of the following statements is true regarding the Good Samaritan law? a) The Good Samaritan law is not applicable to health care workers. b) The Good Samaritan law will not protect the nurse because she did not accept compensation. c) The Good Samaritan law will provide absolute exemption from prosecution. d) The Good Samaritan law will provide legal immunity to the nurse.

The Good Samaritan law will provide legal immunity to the nurse. Explanation: The Good Samaritan laws provide legal immunity to passersby who provide emergency first aid to victims of accidents. Therefore, the law is applicable to the nurse as well; moreover, the nurse did not accept any compensation for the service provided. The law is equally applicable to everyone, but does not provide absolute exemption from prosecution in cases of negligence. Paramedics, ambulance personnel, physicians, and nurses who stop to provide assistance are still held to a higher standard of care because they have training above and beyond that of average laypeople. In cases of gross negligence, health care workers may be charged with a criminal offense.

When making client rounds, the charge nurse observes which action by a staff nurse that would constitute battery? a) The nurse tells the client she cannot leave the hospital because she is seriously ill. b) The staff nurse threatens to restrain the client if she did not take her medication. c) The elderly client refuses the intramuscular injection, but the staff nurse administered it. d) While bathing a client behind pulled curtains, two nurses are discussing a different client.

The elderly client refuses the intramuscular injection, but the staff nurse administered it. Explanation: If the client refuses a procedure or medication and the nurse proceeds with it, it is battery. Threatening a client is assault. Discussing another client within earshot of others is an invasion of privacy. Keeping a client against her wishes, regardless of her health status, is false imprisonment.

The nurse will be caring for a client with a spinal cord injury who has been placed in Crutchfield tongs. The nurse plans which of the following interventions for the client? a. Using a Stryker frame bed b. Calling the physician to determine if the traction is appropriate c. Removing the weights during repositioning d. Leaving assessment of the weights to the physician

a. The nurse would have a Stryker bed available for the client with Crutchfield tongs. The nurse never removes weights applied to Crutchfield tongs. The nurse is able to evaluate that the weights are hanging free and that the amount of weights ordered has been correctly applied.

Injury at C5

The patient should have FULL... -Head and neck control -Shoulder strength -Elbow flexion

Injury at C2 and C3

The patient should have GOOD... -Head and neck sensation The patient should have SOME... -Neck control -Time spent independent of mechanical ventilation for short periods of time

Injury at C4

The patient should have GOOD... -Head and neck sensation -Motor control The patient should have SOME... -Shoulder elevation -Diaphragm movement

A nurse is caring for a client who has undergone coronary angioplasty. The cardiac monitor is showing abnormal ECG waves, indicating arterial fibrillation. The nurse does not recognize the importance of the sign; as a result, the client's condition deteriorates and the client has to be taken up for an emergency procedure. Which of the following describes the nurse's legal liability? a) Felony b) Tort c) Defamation d) Slander

Tort Explanation: A tort is a cause of action in which one person asserts that a physical, emotional, or financial injury was a consequence of another person's actions or failure to act. A tort implies that a person breached his duty to another person. In this case, the nurse had a duty that was breached. A felony is a serious criminal offense, such as murder. Defamation is an act in which untrue information harms a person's reputation. Slander is a character attack uttered orally in the presence of others.

A nurse is caring for a client with a T5 complete spinal cord injury. Upon assessment, the nurse notes flushed skin, diaphoresis above T5, and BP of 162/96. The client reports a severe headache. Which of the following nursing interventions would be appropriate for this client? SATA a. elevate the head of bed to 90 degrees b. loosen constrictive clothing c. use a fan to reduce diaphoresis d. assess for bladder distention and bowel impaction e. administer antihypertensive medication f. place the client in a supine position with legs elevated

a, b, d and e The client is exhibiting s/s of autonomic dysreflexia, The nurse should immediately elevate the HOB to 90 degrees and place the legs in a dependent position to decrease venous return to the heart and increase venous return from the brain. Because tactile stimuli can trigger autonomic dysreflexia, and constrictive clothing should be loosened. The nurse should also assess for distended bladder and bowel impaction and correct any problems. Elevated BP is the most life threatening complication of autonomic dysreflexia because it can cause stroke, MI, or seizures. If removing the triggering event doesn't reduce the client's BP, IV antihypertensives should be administered. A fan should not be used because a cold draft may trigger autonomic dysreflexia.

A nurse is caring for a client who experienced a traumatic head injury and has an intraventricular catheter for ICP monitoring. The nurse should monitor the client for which of the following complications related to the ventriculostomy? a. headache b. infection c. aphasia d. hypertension

b. infection is a complication. Strict asepsis should be used to avoid this life-threatening condition, which may result in meningitis. All others should be monitored, but not the priority.

When the client has a cord transection at T4, which of the following is the primary focus of the nursing assessment? a. renal status b. vascular status c. GI function d. biliary function

b. vascular status The sympathetic feedback system is lost and the client is at risk for hypotension and bradycardia

A registered nurse enters a client's room and observes the unlicensed assistive personnel (UAP) pushing a client down on the bed. The client starts crying and informs the UAP that he needs to go to the bathroom. The UAP holds the client down and tells him he was just in the bathroom. The nurse observing this incident is aware that the UAP's action is an example of: a) assault. b) fraud. c) defamation of character. d) battery.

battery. Explanation: The UAP is engaging in battery, which is an assault that is carried out and includes willful, angry, and violent or negligent touching of another person's body or clothes or anything attached to (or held by) that other person. Assault is a threat or an attempt to make bodily contact with another person without that person's consent. Fraud is willful and purposeful misrepresentation that could cause, or has caused, loss or harm to a person or property. Defamation of character is an intentional tort in which one party makes derogatory remarks about another that harms the other party's reputation.

A nurse is conducting teaching for a client with a spinal cord injury who is being discharged with halo traction. The nurse concludes that further instruction is necessary upon learning that the client intends to: a. Monitor balance carefully. b. Care for the skin under the vest daily. c. Drive in the daytime only. d. Drink with a straw.

c. The client with halo traction cannot drive because the traction limits mobility and impairs range of vision. The client should drink with a straw and cut foods into small pieces to facilitate chewing. The halo can cause imbalance, so the client is cautioned to monitor balance carefully. The client is taught to care for the skin under the vest.

A client with SCI is at risk for experiencing autonomic dysreflexia. The nurse would carefully monitor for which of the following manifestations? a. tachycardia b. hypotension c. severe, throbbing headache d. cyanosis of the head and neck

c. severe headache other manifestations include: flushed face and neck bradycardia severe hypertension nausea sweating nasal stuffiness blurred vision

Anterior Cord Syndrome is characterized by: a. complete loss of positional sense below the level of injury b. complete loss of motor function below the level of injury c. variable loss of motor and sensory level and maintenance of positional sense below the level of injury d. a complete disruption of all spinal tissue below the level of injury

c. variable loss of motor and sensory level and maintenance of positional sense below the level of injury

After reporting to work for a night shift, the nurse learns that the unit will be understaffed because two RNs called out sick. As a result, each nurse on the unit will need to provide care for an additional four acute clients, in addition to her regular client assignment. Which statement is true for this nurse when working in understaffed circumstances? a) The nurse must document that float staff, nurses on overtime, and part-time staff were contacted in an effort to fill the gaps in care. b) Understaffing constitutes an extenuating circumstance that creates a temporarily lower expectation for care for the nurse. c) The nurse is legally obliged to refuse to provide care when understaffing creates the potential for unsafe conditions. d) The nurse will be legally held to the same standards of care as when staffing levels are normal.

he nurse will be legally held to the same standards of care as when staffing levels are normal. Explanation: The claim of being overworked does not constitute a legal defense, and both the potential for liability and standards of care remain unchanged despite an increased client assignment. While it is prudent to make all realistic attempts to fill the gaps in staffing, documenting these efforts does not change the nurse's legal position. A nurse has the right to refuse an unsafe client assignment but the nurse is not legally obliged to withhold care

Legal safeguards are in place in the nursing practice to protect the nurse from exposure to legal risks as well as to protect the client from harm. What are examples of legal safeguards for the nurse? Select all that apply. a) The nurse educates the client about The Patient Care Partnership. b) The nurse obtains informed consent from a client to perform a procedure. c) The nurse executes physician orders without questioning them. d) The nurse claims management is responsible for inadequate staffing leading to negligence. e) The nurse documents all client care in a timely manner. f) The physician is responsible for administration of a wrongly prescribed medication

• The nurse educates the client about The Patient Care Partnership. • The nurse obtains informed consent from a client to perform a procedure. • The nurse documents all client care in a timely manner. Explanation: Examples of legal safeguards for the nurse would include the nurse obtaining informed consent from a client, the nurse educating the client about The Patient Care Partnership, and the nurse documenting all client care in a timely manner. Legal safeguards for the nurse would not include the nurse executing physician orders without questioning them. Legal safeguards for the nurse would not include the nurse claiming management is responsible for inadequate staffing leading to negligence. Legal safeguards for the nurse would not include the physician being responsible for administration of a wrongly prescribed medication

Nurses on the unit are discussing their interactions with parents of children with special needs. Which comment made by a nurse would immediately prompt the nursing supervisor to intervene? "It is tiring caring for special needs clients and their families day after day." "I have suggested that the parents of two of my clients talk with each other for support." "The parent will need a specially designed car seat to transport the child home safely." "That parent just does not appreciate how much nurses know about working with special needs kids."

"That parent just does not appreciate how much nurses know about working with special needs kids." o The comment about a parent's appreciation of nursing knowledge needs investigation by the supervisor first. Parents should be engaged as equal partners in the care of their children with special needs. They are experts and understand the full range of their child's care and have found effective ways to provide it. The nursing supervisor would then investigate the nurse's feeling of tiredness as this could lead to nurse burnout. The other comments are appropriate to the situation and involve giving information, checking for understanding, and encouraging a parent-to-parent connection.

34. The nurse is providing health education to a patient who has a C6 spinal cord injury. The patient asks why autonomic dysreflexia is considered an emergency. What would be the nurses best answer? A) The sudden increase in BP can raise the ICP or rupture a cerebral blood vessel. B) The suddenness of the onset of the syndrome tells us the body is struggling to maintain its normal state. C) Autonomic dysreflexia causes permanent damage to delicate nerve fibers that are healing. D) The sudden, severe headache increases muscle tone and can cause further nerve damage.

Ans: A Feedback: The sudden increase in BP may cause a rupture of one or more cerebral blood vessels or lead to increased ICP. Autonomic dysreflexia does not directly cause nerve damage.

7. An ED nurse has just received a call from EMS that they are transporting a 17-year-old man who has just sustained a spinal cord injury (SCI). The nurse recognizes that the most common cause of this type of injury is what? A) Sports-related injuries B) Acts of violence C) Injuries due to a fall D) Motor vehicle accidents

Ans: D Feedback: The most common causes of SCIs are motor vehicle crashes (46%), falls (22%), violence (16%), and sports (12%).

A nurse caring for a group of clients on the neurological floor is working with a nursing assistant and a licensed practical nurse (LPN). Their client care assignment consists of a client with new-onset seizure activity, a client with Alzheimer's disease, and a client who experienced a stroke. While administering medications, the registered nurse receives a call from the intensive care unit (ICU), saying a client who underwent a craniotomy 24 hours ago must be transferred to make room for a new admission. The ancillary staff is providing morning care and assisting clients with breakfast. How should the nurse direct the staff to facilitate a timely transfer? Notify the supervisor that the client care assignment is unsafe with the addition of the new client, and insist the supervisor assist with the assignment. Administer the medications quickly and ask the nursing assistant and LPN to finish providing care for the clients. Ask the nursing assistant to finish providing care to the clients and the LPN to administer the remaining medications so the registered nurse can accept the client from the ICU. Tell the ICU they have to wait to transfer the client because everyone is too busy to accept the client.

Ask the nursing assistant to finish providing care to the clients and the LPN to administer the remaining medications so the registered nurse can accept the client from the ICU. o The registered nurse should use the ancillary staff to help effectively manage the group of clients. While the registered nurse accepts the client from the ICU, the nursing assistant can provide care for the clients, and the LPN can administer the remaining medications. Telling the ICU to wait or notifying the supervisor that they must assist are incorrect options because the nurse should assess the situation and use the ancillary staff appropriately. The nurse has adequate staff to safely provide care for this group of clients. The nurse shouldn't administer medications quickly because haste is an unsafe practice that could lead to a medication error. Instead of rushing, the nurse should delegate the responsibility to the LPN.

Nurses who work in a pediatric psychiatric-mental health facility should do what? Develop self-awareness of issues that remind them of their own childhood and adolescence. Ensure that their own physical and mental health needs are placed above those of the clients. Use self-disclosure of personal struggles with problems of childhood and adolescence with clients. Ensure that their professional life is a higher priority than their personal life.

Develop self-awareness of issues that remind them of their own childhood and adolescence. o To care for themselves, nurses need to recognize and discuss their job-related stressors. They should acknowledge and deal with issues that remind them of their own childhood and adolescence. Equally important, they need to attend to their own physical and mental health. Proper nutrition, rest and sleep, exercise, health care, maturity, and balance in personal and professional lives maximize the energy available to work therapeutically with youth and their families.

The nursing instructor is teaching a group of nursing students about the various responsibilities of the labor and delivery medical team. The instructor determines the session is successful when the students correctly choose which function as the primary role of the LPN/LVN members of the team? Assist the providers in the delivery room. Provide direct independent care to the client. Provide care under the supervision of an RN. Observatory to assist the RN.

Provide care under the supervision of an RN. o The LPN may provide care within the appropriate scope of practice under the direct supervision of an RN. The RN is responsible for providing direct independent care of the client. Both LPN/LVNs and RNs assist health care providers in the delivery room. The LPN/LVNs provide more than just observatory functions for the RN.

The registered nurse (RN) and unlicensed assistive personnel (UAP) are caring for a pediatric client with an immune disorder receiving a stem cell transplant. Which action by the UAP will cause the RN to intervene? The UAP wears a mask when entering the client's room. The UAP places a lunch tray in the client's room. The UAP takes a rectal temperature on the client. The UAP assists the client to ambulate in the room.

The UAP takes a rectal temperature on the client. o Precautions must be taken to protect the client from infection. The RN would intervene if the UAP takes a rectal temperature because this increases the client's risk for infection. The client should not receive rectal suppositories as well. The RN would ensure meticulous oral care is provided and encourage appropriate and adequate nutrition. Delivering a meal tray, wearing a mask when entering the room, and assisting the client to ambulate in the room are all appropriate actions by the UAP.

An experienced pediatric nurse is orienting a new graduate nurse. Which action by the new graduate would require intervention by the experienced nurse? The nurse offers the medicine to the child and says to "take this liquid candy." The nurse identifies the child using the ID band and asking the child's name. The nurse asks the experienced nurse to check the dosage calculations. The nurse looks up the medication in the Harriet Lane book.

The nurse offers the medicine to the child and says to "take this liquid candy." o It is inappropriate to call medication candy, as it is deceptive and children may try to take the "candy" at another time on their own. It is appropriate for the new nurse to look up the medication, have someone double-check dosage calculations, and identify the child with the ID band and the child's name.

A student is choosing an educational path and desires a nursing degree with a track for community nursing and leadership and that allows for classes in liberal arts. The student would best be suited in which type of program? certification in a nursing specialty licensed practical nursing program baccalaureate program diploma nursing program

baccalaureate program o The baccalaureate degree in nursing offers students a full college or university education, with a background in liberal arts. It is an intense program as it includes a focus on nursing leadership skills with additional requirements for clinical practice labs and clinical internships throughout its duration. Licensed practical nursing programs, certification in a nursing specialty, and diploma nursing programs are shorter length programs who curriculum is focused more on clinical nursing skills.

A nurse is performing a sterile dressing change on a client's abdominal incision. While establishing the sterile field, the nurse drops the forceps on the floor. The nurse is unable to continue with the dressing change because there are no extra supplies in the room, and no one is present to bring new forceps. The nurse failed to organize: logistics and planning. skills and assistance. environment and client. equipment and personnel.

equipment and personnel. o A key component of the organizing interventions is to ensure adequate equipment (extra supplies) and sufficient personnel to assist with more complex tasks. Skills are first learned in nursing school but then validated with policies and procedures of the institution. Assistance is necessary to assist with the skill but is not the main issue in this scenario. Environment would be related to the lighting and space. Client issues would be the correct response if the client was cognitively aware and not confused. Logistics and planning may be related to other issues such as making sure all the elements such as personnel, client, environment, and assistance are all present.

9. Paramedics have brought an intubated patient to the RD following a head injury due to acceleration- deceleration motor vehicle accident. Increased ICP is suspected. Appropriate nursing interventions would include which of the following? A) Keep the head of the bed (HOB) flat at all times. B) Teach the patient to perform the Valsalva maneuver. C) Administer benzodiazepines on a PRN basis. D) Perform endotracheal suctioning every hour.

Ans: C Feedback: -1281 If the patient with a brain injury is very agitated, benzodiazepines are the most commonly used sedatives and do not affect cerebral blood flow or ICP. The HOB should be elevated 30 degrees. Suctioning should be done a limited basis, due to increasing the pressure in the cranium. The Valsalva maneuver is to be avoided. This also causes increased ICP.

A nurse manager on a pediatric unit is making assignments for the day. The nurse's goals are atraumatic care for pediatric clients and minimizing parent-child separation. What method of care delivery should the nurse implement? Assign a medication nurse and a primary nurse. Assign unlicensed assistive personnel to care for the child to give the parents a break. Assign a core primary nurse. Assign a team of nurses and unlicensed assistive personnel.

Assign a core primary nurse. o Family-centered care is the gold standard for pediatric nursing. It decreases anxiety for both the parent and the child, recovery times are shortened and pain management is enhanced. When a primary nurse is assigned to the child and family, they have an identifiable source to help meet their needs. Oftentimes when more than one person is providing care, effective communication is lost. The family is the primary source for the child and they should not be separated. Having a medication nurse and primary nurses tends to fragment care. The unlicensed assistive personnel can provide basic care for the child, but the parents to be offered to communicate how much involvement they wish in their child's care.

The nurse is preparing to teach a class on cultural differences to a group of clients from the community. Which principle of culture will the nurse consider while planning the class information? Culture is always centered around religious activities and beliefs. Culture is determined by one's own morals and personal beliefs. Individuals are born with an understanding of their specific culture. Each generation learns about culture from family and the community.

Each generation learns about culture from family and the community. o Culture is a shared, not individual, system of beliefs, values, and behavioral expectations that provide social structure for daily living. Culture includes the beliefs, habits, likes and dislikes, and customs and rituals learned from family and the community through a process called enculturation. Individuals are not born with a sense or awareness of culture. Some cultures are heavily centered on religious practices and customs, however, all are not.

Several day-shift nurses complain that the night-shift nurses aren't performing the daily calibration of the capillary glucose monitoring apparatus, which is their responsibility. It would be most prudent for a nurse-manager to review the capillary glucose monitoring calibration log book. counsel the night charge nurse about the discrepancy. immediately remind the night-shift nurses of the daily calibrations. arrange a meeting of the day-shift and night-shift nurses.

review the capillary glucose monitoring calibration log book. o When dealing with complaints, a nurse-manager should always gather data before acting. Therefore, the nurse-manager should review the calibration documentation, then address the findings. It would be inappropriate for the nurse-manager to remind the staff of a responsibility that they may be fulfilling, arrange a meeting that could become confrontational, or counsel the charge nurse before investigating and gathering data relative to the complaint.

A staff nurse is talking with a clinical nurse leader and asks, "What exactly do you do?" Which statement by the clinical nurse leader would be appropriate? "I'm an administrator involved with client care." "My position is one of management." "I collaborate with health care teams to promote client care." "I'm an advanced practice nurse with a specific specialty area."

"I collaborate with health care teams to promote client care." · A clinical nurse leader is a master's-prepared nurse who has earned the certified CNL credential and works collaboratively with the health care team to facilitate, coordinate, and oversee care provided to clients. This role is not considered an administrative or management role, but rather one of leadership in all health care settings. Clinical nurse specialists are advanced practice nurses with specialist education in a defined area of practice.

A client with borderline personality disorder has had 21 admissions to the mental health unit, each of which was precipitated by a suicide attempt resulting in superficial cuts. During this admission, the client has developed a relationship with a highly supportive nurse and has progressed to having a pass to spend an afternoon in a nearby shopping mall. Later the day that the client uses the pass, the nurse is shocked when the emergency department calls to say that the client has just been brought in with multiple self-inflicted lacerations. The nurse asks a supervisor, "Everything was going well. How could this happen?" What response by the supervisor reflects an understanding of borderline personality disorder? "The client's behavior seems personal, but it's really not. Clients with borderline personality disorder act out to relieve anxiety. I suspect having the pass provoked a great deal of anxiety." "I know what you mean. You put a lot of energy into working with this client. It must be disappointing for something like this to happen." "I could have told you this would happen. Clients like these always get you in the end. I hope this will teach you not to get so involved." "I wonder if all this could have been avoided if I'd clued you in on the client. This is a usual pattern. The client burned me once, too, when I first worked here."

"The client's behavior seems personal, but it's really not. Clients with borderline personality disorder act out to relieve anxiety. I suspect having the pass provoked a great deal of anxiety." o It will be instructive for the more experienced nurse to share with the rationale behind self-inflicted injuries as a feature of borderline personality disorder. Understanding professional boundaries is a vital nursing role. Reinforcing an overhelping relationship or boundary blurring would not be professional or instructive. Berating the client and the client's behaviors would not be professional.

When a novice psychiatric nurse shares with the nurse manager that talking about sexual abuse with clients is very uncomfortable, which would be the most effective response from the nurse manager? "It would be great if you could attend an in-service on therapeutic communication." "Have you ever been sexually abused?" "I can take that client off of your assignment this shift." "What specifically makes you uncomfortable?"

"What specifically makes you uncomfortable?" o It is important for the novice nurse to identify what it is about discussing sexual abuse that is anxiety producing so that those issues can be addressed and resolved. Asking this question will assist the novice nurse in engaging in self-reflection that can lead to a greater awareness of self and thus enhance the ability to be therapeutic. Suggesting the nurse have such abuse victims released from the nurse's care ignores the problem and minimizes the nurse's therapeutic effectiveness. Arranging for training is appropriate only if it is discovered that the problem relates to a lack of skills related to the nurse's therapeutic communication techniques. While prior sexual abuse may be the cause of the nurse's discomfort, it is not appropriate for the nurse manager to initiate this discussion in that manner.

Characteristics of Autonomic Dysreflexia

-Potentially life-threatening hypertension -Bradycardia -Severe, pounding headache -Nausea Blurred vision -Flushed skin -Diaphoresis -Goosebumps -Nasal congestion -Anxiety

Which nursing student would most likely be held liable for negligence? a) A nursing student administers medication to a resident, while working as an unlicensed assistive personnel (UAP) at a local nursing home. b) A nursing student reports that insulin was not administered to the client by the nurse on the previous shift. c) A nursing student completes an incident report after administering a medication to a client, who then experienced an adverse reaction to the medication. d) A nursing student performs a dressing change using sterile technique and documents the presence of necrotic tissue in the wound.

A nursing student administers medication to a resident, while working as an unlicensed assistive personnel (UAP) at a local nursing home. Explanation: The nursing student who administers medication to a resident, while working as an unlicensed assistive personnel (UAP) at a local nursing home, is performing a task outside the scope of the job responsibilities of a UAP. The other options demonstrate legally defensible actions by the nursing student

Which process evaluates and recognizes educational programs as having met certain standards? a) Credentialing b) Licensure c) Certification d) Accreditation

Accreditation Explanation: Accreditation is the process by which an educational program is evaluated and recognized as having met certain standards. Credentialing refers to ways in which professional competence is ensured and maintained. Licensure is the process by which a state determines that a candidate meets certain minimum requirements to practice in the profession and grants the license to do so. Certification is the process by which a person who has met certain criteria established by a nongovernmental association is granted recognition in a specified practice area.

16. An elderly woman found with a head injury on the floor of her home is subsequently admitted to the neurologic ICU. What is the best rationale for the following physician orders: elevate the HOB; keep the head in neutral alignment with no neck flexion or head rotation; avoid sharp hip flexion? A) To decrease cerebral arterial pressure B) To avoid impeding venous outflow C) To prevent flexion contractures D) To prevent aspiration of stomach contents

Ans: B Feedback: Any activity or position that impedes venous outflow from the head may contribute to increased volume inside the skull and possibly increase ICP. Cerebral arterial pressure will be affected by the balance between oxygen and carbon dioxide. Flexion contractures are not a priority at this time. Stomach contents could still be aspirated in this position.

19. The nurse is caring for a patient who is rapidly progressing toward brain death. The nurse should be aware of what cardinal signs of brain death? Select all that apply. A) Absence of pain response B) Apnea C) Coma D) Absence of brain stem reflexes E) Absence of deep tendon reflexes

Ans: B, C, D Feedback: The three cardinal signs of brain death upon clinical examination are coma, the absence of brain stem reflexes, and apnea. Absences of pain response and deep tendon reflexes are not necessarily indicative of brain death.

13. A patient with a head injury has been increasingly agitated and the nurse has consequently identified a risk for injury. What is the nurses best intervention for preventing injury? A) Restrain the patient as ordered. B) Administer opioids PRN as ordered. C) Arrange for friends and family members to sit with the patient. D) Pad the side rails of the patients bed.

Ans: D Feedback: To protect the patient from self-injury, the nurse uses padded side rails. The nurse should avoid restraints, because straining against them can increase ICP or cause other injury. Narcotics used to control restless patients should be avoided because these medications can depress respiration, constrict the pupils, and alter the patients responsiveness. Visitors should be limited if the patient is agitated.

Which task is most appropriate for the nurse to delegate to the unlicensed assistive personnel (UAP)? Insertion of a urinary catheter in a client with benign prostatic hypertrophy Preparation of insulin for the diabetic client with an elevated blood glucose level Bed bath for the newly admitted client who has multiple skin lesions Ambulation of the client with a history of falls for the first time after surgery

Bed bath for the newly admitted client who has multiple skin lesions o The safest delegation is to have the UAP bathe the client with skin lesions and report any abnormal findings to the nurse. Preparing insulin is outside of the UAP's scope of practice. The UAP may have the skills to insert an indwelling catheter and ambulate clients, but the clients involved each have qualifiers that complicate the tasks.

The rehabilitation nurse is admitting a client following a spinal cord injury. The nurse concludes that the client has developed brown-Sequard syndrome after detecting which assessment finding in the client? A. Ipsilateral motor loss above the lesion B. Contralateral loss of proprioception C. Hyperanesthesia below the level of the lesion D. Ipsilateral proprioception loss below the lesion

D. Hemisection of the anterior and posterior portions of the spinal cord results in loss of position sense on the same side of the body as the trauma, below the level of injury. Ipsilateral motor loss does not occur above the level of a spinal cord injury. Brown-Sequard syndrome does not result in contralateral loss of proprioception. Hyperanesthesia below the level of the injury is seen in anterior cord syndrome

The nurse manager has recently promoted a staff nurse to the charge nurse position. Which type of power does the charge nurse now have? Implied Explicit Reward Coercive

Explicit o Explicit power is determined by virtue of the nurse's position. A charge nurse is responsible for making decisions and carrying out tasks not performed by staff nurses. Implied power involves a person without a leadership position being in a position of authority with peers. Reward power involves rewarding staff with something that they deem important. Coercive power involves using threats of punishment to force staff to do something they do not want to do.

A nursing facility has recently implemented new policies regarding nurse-to-patient ratios. The nursing staff seems very resistant to the change. How can the nurse manager help the staff accept the change? Hold a unit meeting to discuss how the changes will benefit staff. Use the laissez-faire leadership style to address staff concerns. Institute the changes immediately and collectively to decrease anticipation anxiety. Challenge staff's beliefs and values regarding providing quality patient care.

Hold a unit meeting to discuss how the changes will benefit staff. o Holding meetings allows open communication and opportunities for feedback. Listing the benefits of change to the individual and group also helps with buy-in. Laissez-faire leadership styles tend to increase conflicts and anxiety during times of change. Challenging staff beliefs will increase anxiety and create unpleasant work environments. Change should be instituted gradually, if possible.

The nurse manager calls a staff into a unit meeting to discuss patient satisfaction. During the meeting, several staff members assume control. The nurse manager does not intervene to regain control of the group. Which type of leadership style is the nurse embodying? Quantum Laissez-faire Democratic Autocratic

Laissez-faire o Laissez-faire leadership style involves the leader relinquishing power or control to the group. Democratic leadership style involves sharing the decision making process and activities with others who have an interest. Autocratic leadership style involves assuming control over the decisions and activities of the group. Quantum leadership style involves seeing an organization and members as interconnected and collaborative. This style involves change as continually unfolding, and frequently incorporates technology.

A student nurse is scheduled to observe a surgical procedure. The nurse provides the student nurse with education on the dress policy and provides all attire needed to enter a restricted surgical zone. Which observation by the nurse requires immediate intervention? Shoe covers are used. Scrub top and drawstring are tucked into pants. Hair is pulled back and covered by a cap. Mask is placed over nose and extends to bottom lip.

Mask is placed over nose and extends to bottom lip. o The mask should fit tightly, covering the nose and mouth. The mask should extend down past the chin. The mask may not effectively cover the mouth if extended only to the bottom lip. The hair, scrub top, drawstring, and shoe covering are all appropriate and do not require intervention.

A primary unit nurse tells the nurse-manager that a registered nurse hired 6 weeks ago needs an additional week of orientation to function effectively on the staff. Which action is most appropriate for the nurse-manager to take? Meet with the new nurse and the primary nurse and help set up an additional week of orientation. Schedule a staff meeting to find out if there are deficiencies or flaws in the orientation process. Explain to the primary nurse that a 6-week orientation is standard. Meet with the new nurse and question the new nurse about deficits in performance.

Meet with the new nurse and the primary nurse and help set up an additional week of orientation. o The nurse-manager is responsible for adequate orientation of new staff. A need for additional orientation does not mean that a nurse is not competent or that there are deficits in performance. Although a 6-week orientation may be standard, orientation periods should be individualized to meet the needs of the staff as well as provide the best client outcomes. Periodically reviewing and revising the orientation process is a good idea. However, in this case, the most appropriate course of action is to help the new nurse complete the orientation as efficiently as possible.

The health care facility is involved in litigation by four clients. When reviewing the cases, which legal case would the nurse attorney identify to best describe malpractice? a) The nurse administers amoxicillin (Amicar) to a client with known allergies to penicillin. The client has a seizure with resulting respiratory arrest. b) The nurse using proper mechanics assists a client to a locked bed. He slips and breaks his left femur. c) The nurse applies an ice pack to a client's lower back without an order and he feels better. d) The nurse administered the wrong medication to the client, who had one episode of vomiting 5 minutes after consuming the medication with no further adverse reactions.

The nurse administers amoxicillin (Amicar) to a client with known allergies to penicillin. The client has a seizure with resulting respiratory arrest Explanation: All elements of liability are in place for administering amoxicillin to a client with documented allergies to penicillin: the nurse had a duty, but breached it when giving the medication. There also was causation (amoxicillin) and harm (seizures and respiratory arrest). The nurse is negligent when applying an ice pack without an order. The nurse used proper mechanics, so the client fall is an accident even though harm occurred. Giving the wrong medication could be cause for malpractice, but there was no harm

30. The nurse is caring for a patient whose spinal cord injury has caused recent muscle spasticity. What medication should the nurse expect to be ordered to control this? A) Baclofen (Lioresal) B) Dexamethasone (Decadron) C) Mannitol (Osmitrol) D) Phenobarbital (Luminal)

ans: A Feedback: Baclofen is classified as an antispasmodic agent in the treatment of muscles spasms related to spinal cord injury. Decadron is an anti-inflammatory medication used to decrease inflammation in both SCI and head injury. Mannitol is used to decrease cerebral edema in patients with head injury. Phenobarbital is an anticonvulsant that is used in the treatment of seizure activity.

39. The nurse recognizes that a patient with a SCI is at risk for muscle spasticity. How can the nurse best prevent this complication of an SCI? A) Position the patient in a high Fowlers position when in bed. B) Support the knees with a pillow when the patient is in bed. C) Perform passive ROM exercises as ordered. D) Administer NSAIDs as ordered.

ans: C Feedback: Passive ROM exercises can prevent muscle spasticity following SCI. NSAIDs are not used for this purpose. Pillows and sitting upright do not directly address the patients risk of muscle spasticity.

A friend tells you not to even think about carrying your own insurance because "you'll be a magnet for attorneys trying to make a buck." When you seek the advice of the American Nurses Association, you are likely to read which of the following reasons for purchasing a personal professional liability insurance policy? (1) Protection of the nurse's best interests (2) Limitations of employer's coverage (3) Care or advice given outside of work (4) Protection of the institution's best interests a) (1) b) (1) and (2) c) (1), (2), (3) d) All of the above

c) (1) Protection of the nurse's best interests (2) Limitations of employer's coverage (3) Care or advice given outside of work The ANA (1990) lists these for purchasing a personal professional liability insurance policy.

A 20-year-old client who is engaged to be married is injured in a hit-and-run accident. The spinal cord injury leaves the client paralyzed from the waist down. When planning care for this client, the nurse expects to address which of the following? a. Anger b. Fatigue c. Grieving d. Bargaining

c. This client is just beginning adult life and will no longer be able to complete developmental tasks as planned, such as raising a family, so the nurse expects this client to grieve the loss of life as previously anticipated. Anger and bargaining are two facets of grieving and the client will be faced with the whole grieving process, not just parts. Fatigue may or may not be an issue for this client.

After one month of therapy, the client in spinal shock begins to experience muscle spasms in his legs. He calls the nurse in excitement to report the movement. Which of the following responses by the nurse would be the most accurate? a. these movements indicate that the damaged nerves are healing b. this is a good sign. Keep trying to move all the affected muscles c. the return of movement means that eventually you will walk again d. the movements occur from muscle reflexes that can't be initiated or controlled by the brain.

d. The movements occur from muscle reflexes and cannot be initiated or controlled by the brain. After the period of spinal shock, the muscles gradually become spastic owing to an increased sensitivity of the lower motor neurons. It is an expected occurrence and does not indicate that healing is taking place.

Which action may a nurse on the orthopedic unit safely delegate to a licensed practical nurse (LPN)? taking a telephone order for pain medications for a postoperative client assessing the hip wound during a dry sterile dressing change teaching a client receiving warfarin about follow-up care obtaining vital signs during blood administration

obtaining vital signs during blood administration o The nurse may safely delegate obtaining vital signs during blood administration to the LPN. Teaching the client taking warfarin about follow-up care, assessing a hip wound, and taking a telephone order are actions that must be taken by the registered nurse because they aren't within the scope of LPN practice.

Nurses complete incident reports as dictated by the agency protocol. What is the primary reason nurses fill out an incident report? a) to document everyday occurrences b) to document the need for disciplinary action c) to improve quality of care d) to initiate litigation

to improve quality of care Explanation: The primary reason to fill out an incident report is to improve the quality of care. Incident reports are not designed to be a means for disciplinary action. Incident reports are designed to identify risks, either in the form of actual risks or potential risks, that can be identified and addressed to improve quality of care. Incident reports are not intended to initiate litigation or document everyday occurrences

A nurse informs the client that the client has no choice and must take a bath in the morning. What type of leadership does this exemplify? Shared governance Institutional governance Directive leadership Participative leadership

Directive leadership o Directive (also known as autocratic or authoritarian) leadership describes a leader who makes all the decisions and tells followers what to do. Democratic, or participative, leadership style and shared governance involve sharing the decision-making process and activities with others who have an interest. Institutional governance is governance by the institution.

36. Splints have been ordered for a patient who is at risk of developing footdrop following a spinal cord injury. The nurse caring for this patient knows that the splints are removed and reapplied when? A) At the patients request B) Each morning and evening C) Every 2 hours D) One hour prior to mobility exercises

ans: C Feedback: The feet are prone to footdrop; therefore, various types of splints are used to prevent footdrop. When used, the splints are removed and reapplied every 2 hours.

26. The nurse planning the care of a patient with head injuries is addressing the patients nursing diagnosis of sleep deprivation. What action should the nurse implement? A) Administer a benzodiazepine at bedtime each night. B) Do not disturb the patient between 2200 and 0600. C) Cluster overnight nursing activities to minimize disturbances. D) Ensure that the patient does not sleep during the day.

ans: C Feedback: To allow the patient longer times of uninterrupted sleep and rest, the nurse can group nursing care activities so that the patient is disturbed less frequently. However, it is impractical and unsafe to provide no care for an 8-hour period. The use of benzodiazepines should be avoided.

A registered nurse is delegating activities to unlicensed assistive personnel (UAP) on a hospital unit. Which activities could this nurse normally delegate? Select all that apply. The determination of a nursing diagnosis for a client with breast cancer Taking routine vital signs Giving a bed bath to a client Transferring a client to another floor Administering medications to clients Planning education for a client with a colostomy

Taking routine vital signs Giving a bed bath to a client Transferring a client to another floor o The nurse should be familiar with guidelines for delegating nursing care. The nurse could delegate the following tasks to UAP: giving a bed bath to a client, taking routine vital signs, and transferring a client to another floor. The nurse could not delegate the administering of medications, planning client education for a client with a colostomy, or the determination of a nursing diagnosis.

27. The nurse has implemented interventions aimed at facilitating family coping in the care of a patient with a traumatic brain injury. How can the nurse best facilitate family coping? A) Help the family understand that the patient could have died. B) Emphasize the importance of accepting the patients new limitations. C) Have the members of the family plan the patients inpatient care. D) Assist the family in setting appropriate short-term goals.

ans: D Feedback: Helpful interventions to facilitate coping include providing family members with accurate and honest information and encouraging them to continue to set well-defined, short-term goals. Stating that a patients condition could be worse downplays their concerns. Emphasizing the importance of acceptance may not necessarily help the family accept the patients condition. Family members cannot normally plan a patients hospital care, although they may contribute to the care in some ways.

The primary responsibility of the nurse manager is to: provide direct client care. direct discharge planning. create unit plans and budgets. evaluate nursing care plans.

create unit plans and budgets. o The primary responsibility of a nurse manager is to create plans and budgets for the unit as a whole. Staff nurses are responsible for direct patient care, discharge planning, and evaluating nursing care plans.

Following notification of two client falls on the unit, a nurse manager decides a formal investigation is necessary and informs the staff. Which statement indicates the primary reason the nurse manager would perform an investigation to determine the causes of the falls? "I want to determine exactly what happened and why the two clients fell." "I would like to know which staff members were on duty when the falls occurred." "I would like to establish the causes and trends related to client falls." "I want to identify the environmental factors that contributed to the falls."

"I would like to establish the causes and trends related to client falls." o The analysis will identify variations in performance that cause or could cause the clients to fall. It will identify the answer to the question of "How can we prevent this from happening again?" It does not place blame on individuals; rather, it looks at systems and processes. Limiting the focus of the inquiry to the specific clients or staff members does not meet the criteria for root cause analysis, because those foci are too narrow in scope. Similarly, limiting the inquiry to only environmental factors could result in missed data important to the contributing factors for the falls. The nurse examines all potential contributing factors to develop the most helpful investigation.

What nursing intervention should the nurse perform when a client with spinal trauma may not be able to cough?

-Suctioning the airway helps remove secretions -An artificial airway increases the production of respiratory secretions

14. A patient with a C5 spinal cord injury is tetraplegic. After being moved out of the ICU, the patient complains of a severe throbbing headache. What should the nurse do first? A) Check the patients indwelling urinary catheter for kinks to ensure patency. B) Lower the HOB to improve perfusion. C) Administer analgesia. D) Reassure the patient that headaches are expected after spinal cord injuries.

Ans: A Feedback: A severe throbbing headache is a common symptom of autonomic dysreflexia, which occurs after injuries to the spinal cord above T6. The syndrome is usually brought on by sympathetic stimulation, such as bowel and bladder distention. Lowering the HOB can increase ICP. Before administering analgesia, the nurse should check the patients catheter, record vital signs, and perform an abdominal assessment. A severe throbbing headache is a dangerous symptom in this patient and is not expected.

The nurse is coordinating care for a client with continuous pulse oximetry who requires pharyngeal suctioning. To which staff member should the nurse avoid delegating the task of suctioning? Registered nurse Nursing assistant who is a nursing student Licensed practical nurse A senior nursing student present for clinical

Nursing assistant who is a nursing student o The nurse should avoid delegating this client to the nursing assistant who is a nursing student. Suctioning and the associated evaluation of the client would be within the scope of practice of the registered nurse, licensed practical nurse, and the senior nursing student present for clinical.

When in a spinal cord injury does Autonomic Dysreflexia occur?

Only after spinal shock has resolved

The nurse manager of a medical-surgical unit is planning to make changes, because the unit is understaffed. What is the first action the manager takes to plan the change for the unit? Plan to make the change Determine and analyze solutions to the problem Recognize the symptoms that indicate a change is needed and collect data Evaluate the interventions made to correct the issue

Recognize the symptoms that indicate a change is needed and collect data o The first step in planned change is recognizing symptoms that indicate a change is needed and collect supporting data. Determining and analyzing solutions to the problem comes after recognizing the symptoms. Planning and evaluation are the end results of the planned change.

Injuries related to lifting or transferring patients occur in the health care setting and may be considered a work-related injury. Which law was intended to reduce work-related injuries and illnesses? a) The Occupational Safety and Health Act of 1970 b) The Health Care Quality Improvement Act of 1986 c) Title VII of the Civil Rights Act of 1964 d) Americans with Disabilities Act of 1990

The Occupational Safety and Health Act of 1970 Explanation: The Occupational Safety and Health Act of 1970 set legal standards in the United States in an effort to ensure safe and healthful working conditions for men and women. The Health Care Quality Improvement Act of 1986 was enacted to encourage health care practitioners to identify and discipline practitioners who engage in unprofessional conduct, and to restrict the ability of incompetent practitioners to move from state to state without disclosure of the practitioner's previous performance. Title VII of the Civil Rights Act of 1964 protects employees from discrimination. The Americans with Disabilities Act of 1990 prohibits discrimination against disabled people and requires covered entities to reasonably accommodate individuals who are protected by the Act.

A nurse is working on a medical surgical unit with a licensed practical/vocational nurse (LPN/LVN). Which action made by the nurse is considered negligent if injury results from this action? a) calling the healthcare provider about abnormal lab results b) completing a physical assessment on a newly admitted client c) delegating all wound care and oral medication administration to the LPN/LVN d) asking the LPN/LVN to teach a new diabetic client how to administer insulin

asking the LPN/LVN to teach a new diabetic client how to administer insulin Explanation: Negligence is harm that results because a person did not act reasonably. As nurses perform the role of delegators, they must know which tasks are legal and appropriate for particular healthcare providers to perform (scope of practice), as well as the policy for the facility at which they are employed. Teaching is not in the current scope of practice for a LPN/LVN, and can be considered negligent. The other actions are within the scope of practice for registered nurses

Professional regulations and laws that govern nursing practice are primarily in place for which reason? a) to limit the number of nurses in practice b) to ensure that practicing nurses are of good moral standing c) to protect the safety of the public d) to ensure that enough new nurses are always available

to protect the safety of the public Explanation: Governing bodies, professional regulations, and laws are in place to protect the public by ensuring that nurses are accountable for safe, competent, and ethical nursing practice. The other options do not describe accurately the role and responsibility of the governing bodies and the regulations and laws of nursing.

A nurse administrator is observing the behavior of nurses in the hospital. Which behaviors would the nurse administrator consider inappropriate? Select all that apply. A nurse speaking to a client at a distance of 4 feet A nurse holding the hand of a client who is depressed because of the client's child's chronic illness. A nurse palpating the neck of a client during the assessment A nurse hugging a client who had come in for an initial visit A nurse speaking to a depressed client in a very strict, disciplinarian tone

A nurse hugging a client who had come in for an initial visit A nurse speaking to a depressed client in a very strict, disciplinarian tone o Hugging a client who has come in for an initial visit is an inappropriate nursing behavior. This behavior indicates that the nurse is not maintaining professional boundaries. Speaking to a depressed client in a very strict, disciplinarian tone is an inappropriate nursing behavior. The depressed client needs support, and speaking in a strict tone would not be helpful to the client. Speaking to a client at a distance of 3-6 feet facilitates good therapeutic communication. Holding the hand of a client who is depressed because of her child's chronic illness is an appropriate nursing behavior, as the client needs a person to support the client at this moment.

23. A 13-year-old was brought to the ED, unconscious, after being hit in the head by a baseball. When the child regains consciousness, 5 hours after being admitted, he cannot remember the traumatic event. MRI shows no structural sign of injury. What injury would the nurse suspect the patient has? A) Diffuse axonal injury B) Grade 1 concussion with frontal lobe involvement C) Contusion D) Grade 3 concussion with temporal lobe involvement

Ans: D Feedback: In a grade 3 concussion there is a loss of consciousness lasting from seconds to minutes. Temporal lobe involvement results in amnesia. Frontal lobe involvement can cause uncharacteristic behavior and a grade 1 concussion does not involve loss of consciousness. Diagnostic studies may show no apparent structural sign of injury, but the duration of unconsciousness is an indicator of the severity of the concussion. Diffuse axonal injury (DAI) results from widespread shearing and rotational forces that produce damage throughout the brainto axons in the cerebral hemispheres, corpus callosum, and brain stem. In cerebral contusion, a moderate to severe head injury, the brain is bruised and damaged in a specific area because of severe acceleration-deceleration force or blunt trauma.

A nurse manager of a hospital unit is working within a decentralized management structure. Which nursing action best exemplifies this type of system? Decisions are made by those who are most knowledgeable about the issue. Senior managers make all the decisions. Nurses are not intimately involved in decisions involving client care. Nurse managers are not accountable for clients, staffing, supplies, or budgets.

Decisions are made by those who are most knowledgeable about the issue. o The best example of a nurse manager of a hospital unit working within a decentralized management structure would be that decisions are made by those who are most knowledgeable about the issue. Nurses would be greatly involved in decisions involving client care. Senior managers would not make all the decisions within a decentralized management structure. Nurse managers could be accountable for clients, staffing, supplies, and/or budgets.

A nurse from a surgical unit is asked to work on the pediatric unit during a staffing shortage. The surgical nurse has not worked in pediatrics for 10 years and is not familiar with the unit. The surgical nurse approaches the nurse manager and claims not to be competent to work on the pediatric unit. What should the nurse manager do? Find another nurse to cover the unit and send the nurse back to the surgery unit. Give the nurse the lightest workload on the unit. Tell the nurse that as an RN, the nurse should be competent to work in any area. Tell the nurse to buddy up with someone else and do the best that the nurse can do.

Find another nurse to cover the unit and send the nurse back to the surgery unit. o Nurses are accountable for their practice and must recognize the limitations of their own competency. To the extent possible, the nurse manager must ensure nurses working on their units have the required knowledge, skills, and competencies. The other options are incorrect because they do not ensure that the clients are receiving care from the most competent nurse.

The RN is working with hospital administrators to transform care at their facility. Which nursing competency will be critical for the nurse to utilize? Do things the way they have always been done Correctly utilize and troubleshoot high-tech equipment Navigate the electronic medical records system Work effectively in interdisciplinary teams

Work effectively in interdisciplinary teams o The RN working with administrators to transform care will need to be able to work effectively as part of an interdisciplinary team. The nurse will need to work as a team member with members of the administration, as well as representatives from other health disciplines involved in the project. The ability to use and troubleshoot equipment and to navigate the electronic medical records are important to the nurse, but will not necessarily help when working with administration to transform care. Doing things the way they have always been done is a barrier to transformation of care.

The interdisciplinary team is discussing the best approach to planning the care for a client with complex psychiatric-mental health needs. When determining which tasks can be performed by the psychiatric-mental health registered nurse (PMH-RN) and which must be performed by the psychiatric-mental health advanced practice registered nurse (PMH-APRN), the team should prioritize guidelines from what source? The recognized norms in the jurisdiction where the team is working The policies and procedures manual of the institution The American Nurses Association Standards of Practice The World Health Organization Guidelines for Nursing Practice

The American Nurses Association Standards of Practice o The American Nurses Association standards outline the scope of practice for PMH-RNs and PMH-APRNs. These standards override institutional policies and local norms. There is no World Health Organization Guidelines for Nursing Practice.

A charge nurse on a medical-surgical unit is asked by the nurse manager to serve as a mentor to another staff nurse who is less experienced. Which of these would best describe this role? The staff nurse is learning about all the hospital policies from the charge nurse. The charge nurse is being paid to supervise the staff nurse. The charge nurse is providing support for the staff nurse in new responsibilities. The staff nurse is orienting to the unit as a newly hired nurse.

The charge nurse is providing support for the staff nurse in new responsibilities. o A mentor is not a paid position, but, instead, is a person who provides support and encouragement to a less experienced nurse who is learning new responsibilities for a current role or an expanded one. Preceptorship typically is a paid position, and is provided for a new or experienced nurse who is training for a new position on a unit. The preceptor would teach the new nurse about hospital policies and procedures, as well as supervise the nurse in daily assignments.

A nurse manager is considering the reasons for the current problems with the health care system. Which are negative consequences of higher spending in health care? Select all that apply. · Higher spending may result in overutilization of services. · Higher spending guarantees a higher quality of care. · Higher spending may result in overuse of technology. · Higher spending may result in higher quality of care. · Higher spending may result in duplication of services.

· Higher spending may result in overutilization of services. · Higher spending may result in overuse of technology. · Higher spending may result in duplication of services. o Sometimes higher expenditures in health care result in duplication of services, overutilization of services, and overuse of technology. These are all negative outcomes of higher spending. Higher spending may result in a higher quality of care, and this would be a positive outcome of higher spending. Higher spending does not guarantee a higher quality of care.

A registered nurse (RN), a licensed practical nurse (LPN), and an assistive personnel are caring for a group of clients. The RN asks the assistive personnel to check the pulse oximetry level of a client who underwent a laminectomy. The assistive personnel reports that the pulse oximetry reading is 89% on room air. The client has a prescription for oxygen at 2 L/min for a pulse oximetry level below 92%. The RN is currently assessing a postoperative client who just returned from the post anesthesia care unit. How will the RN proceed? Complete the assessment of the new client before attending to the client who underwent laminectomy. Ask the assistive personnel to notify the provider of the low pulse oximetry level. Immediately go the client's room and assess vital signs, administer oxygen at 2 L/minute, and notify the provider. Ask the LPN to obtain vital signs and administer oxygen at 2 L/min to the client who underwent laminectomy.

Ask the LPN to obtain vital signs and administer oxygen at 2 L/min to the client who underwent laminectomy. o Because it's important to get more information about the client with a decreased pulse oximetry level, the RN should ask the LPN to obtain vital signs and administer oxygen as prescribed. The RN must attend to the newly admitted client without delaying treatment to the client who is already in their care. The RN can effectively do this by delegating tasks to an appropriate health team member such as an LPN. The RN doesn't need to immediately attend to the client with a decreased pulse oximetry level; the RN may wait until the newly admitted client's assessment is complete. The primary health care provider doesn't need to be notified at this time because the client has a prescription for oxygen administration.

A client is brought to the emergency department in an unconscious state with a head injury. The client requires surgery to remove a blood clot. What would be the appropriate nursing intervention in keeping with the policy of informed consent prior to a surgical procedure? a) The nurse ensures that the client's family signs the consent form. b) The nurse informs the family about advance directives. c) The nurse informs the family about the living will. d) The nurse ensures that the client signs the consent form.

The nurse ensures that the client's family signs the consent form. Explanation: The nurse should ensure that the client's family signs the consent form. However, in some states and health care facilities, it is the physician who ensures that the client's family signs the consent form. The client cannot sign the consent form if he is not in an alert state or is unable to communicate. If the client is not in a condition to the sign the consent, a family member can sign the consent on his behalf. Advance directives are written statements identifying a competent person's wishes concerning terminal care and are not applicable here. A living will is an instructive form of advance directive; that is, it is a written document that identifies a person's preferences regarding medical interventions to use in a terminal condition, irreversible coma, or persistent vegetative state with no hope of recovery.

A nurse manager informs the staff members during a meeting that unlicensed assistive personnel will no longer be allowed to check patients' blood glucose levels. The nurse manager informs the group this was a new policy on the unit, and discussions will not change the enforcement of this policy. What type of leadership style is the nurse manager demonstrating? · Transformational · Autocratic · Laissez-faire · Democratic

· Autocratic o Autocratic leadership involves the leader assuming complete control of the decisions and activities of the group. An extremely autocratic leader might make all decisions for the workers or followers without considering their ideas or feelings.

Which statement by a staff nurse on the orthopedic floor indicates the need for further staff education? "The continuous passive motion device can decrease the development of adhesions." "Bleeding is a complication associated with the continuous passive motion device." "Monitoring skin integrity is important while the continuous passive motion device is in place." "The client is receiving physical therapy twice per day, so they don't need a continuous passive motion device."

"The client is receiving physical therapy twice per day, so they don't need a continuous passive motion device." o Further staff education is needed when the nurse states that the continuous passive motion device isn't needed because the client receives physical therapy twice per day. The continuous passive motion device should be used in conjunction with physical therapy because the device helps prevent adhesions. Bleeding is a complication associated with the continuous passive motion device; skin integrity should be monitored while the device is in use.

5. A patient is brought to the ED by her family after falling off the roof. A family member tells the nurse that when the patient fell she was knocked out, but came to and seemed okay. Now she is complaining of a severe headache and not feeling well. The care team suspects an epidural hematoma, prompting the nurse to prepare for which priority intervention? A) Insertion of an intracranial monitoring device B) Treatment with antihypertensives -1279 C) Emergency craniotomy D) Administration of anticoagulant therapy

: C Feedback: An epidural hematoma is considered an extreme emergency. Marked neurologic deficit or respiratory arrest can occur within minutes. Treatment consists of making an opening through the skull to decrease ICP emergently, remove the clot, and control the bleeding. Antihypertensive medications would not be a priority. Anticoagulant therapy should not be ordered for a patient who has a cranial bleed. This could further increase bleeding activity. Insertion of an intracranial monitoring device may be done during the surgery, but is not priority for this patient.

The charge nurse is planning staffing on a pediatric unit. Which client will the charge nurse assign to the registered nurse? the 12-year-old client with a urinary tract infection taking oral antibiotics the 8-year-old client recovering from an appendectomy who is ambulating the 1-year-old client with a respiratory disorder prescribed oxygen therapy the 6-year-old client admitted yesterday for oral rehydration following a mild gastrointestinal disorder

the 1-year-old client with a respiratory disorder prescribed oxygen therapy o The charge nurse would assign the RN to the most unstable client, which is the client with a respiratory disorder who is only 1 year of age. According to Child Health USA 2010, diseases of the respiratory system account for the majority of hospitalizations in children younger than 5 years of age, indicating this is a common occurrence. All other clients are stable and could be cared for by licensed practical nurses at this time.