emergency

A client's spouse has expressed great concern about the fact that antibiotics have been prescribed for the treatment of pneumonia. The spouse states, "I do not trust all these pharmaceuticals. We are going to treat the pneumonia using the magnet therapy I read about online." What is the nurse's best response?

"It sounds like you have some important questions about the use of medication." When clients present information that is inaccurate or unfounded, the nurse should use this opportunity to discuss the client's doubts and reservations. The nurse needs to obtain more information. A confrontational or condescending approach such as asking about refusal is disrespectful and is unlikely to have the desired effect. The nurse needs to accept what the spouse is saying and provide further information. Contacting the pharmacist is helpful but more information is needed to explore ideas for treatment.

A client comes to the clinic for evaluation. The client tells the nurse, "I have been having headaches and dizziness. I looked it up on the Internet, and I think I might have a brain tumor." The client hands the nurse a printout of what the client found. Which response by the nurse would be most appropriate?

"Tell me more about where you found this information that you gave me." The Internet is full of health information, some of which is not always reputable or accurate. The best response by the nurse would be to investigate the client's information more closely and determine the validity of the information. The client obviously has concerns, and the nurse needs to address these concerns appropriately. By having the client tell the nurse more about the information, the nurse addresses the client's emotional needs as well as determines the validity of the information. Telling the client that a brain tumor is not a real possibility discounts the client's concerns. Telling the client that the idea is ridiculous is condescending and inappropriate. Contacting the primary care provider is inappropriate because it reinforces the client's misinformation.

When discussing advance directives during an admission assessment, a young client asks the nurse, "Do you have an advance directive?" What is the nurse's best response?

"Yes, I completed it after graduation and review it annually." The nurse is in a unique position to serve as a role model and teacher for others of the need to make these decisions when well, and to have this emergency document in place. Also known as "living wills," advance directives are generally thought to be necessary only for the elderly and seriously ill. Ideally the nurse did complete it upon initially learning of its importance, and reviews it for accuracy and possible revision on a regular basis. Advance directives are not related to being single and healthy, or having served in the military. It is best to take the time to complete this vital document.

A client has been admitted to the hospital for treatment of kidney stones. The client asks the nurse where the Atkins diet items are on the menu. What is the nurse's understanding of the diagnosis and diet?

A diet high in protein may strain the kidney function.

An 86-year-old client with dementia is being discharged after treatment for a hip fracture. In reviewing the notes, the nurse identifies that the sole caregiver at home is an adult child with a moderate intellectual disability. What is the most important action the nurse should ensure is in place before discharging the client home?

An immediate home visit is arranged with the visiting nurse service and the social worker. The visiting nurse service will be the primary service to coordinate all care in the home after discharge. It will be necessary for them to quickly assess the needs of this family to determine the level of supervision and support they will require. This care may require more than a daily visit, as well as support from a home health aide. Care will necessarily include physical therapy and social work services. If the visiting nurse service determines an increased level of care is required, they will provide the necessary documentation to the client's health insurance company.

An HIV-positive client who has been treated with antiretroviral therapy for two decades presents at the emergency department with symptoms typically associated with myocardial infarction. The nurse assessing this client should immediately recognize which factor associated with chronic HIV?

Chronic HIV clients are at increased risk for cardiovascular disease.

After being informed that a client is to be admitted to the hospital for stabilization of the client's diabetes, the client's child returns to the hospital 6 hours later to find that the client remains on a stretcher in the emergency department hallway. The child begins to shout "I will not allow my insurance to pay for your failure to provide care." What is the best action for the nurse to take in this situation?

Ensure the comfort and security of the client and meet privately with the family member. It is imperative to insure that the client who remains in an interim status awaiting admission to a hospital ward bed is safe and comfortable, as well as being reassured that this person is being cared for. The nurse should then meet privately with the family member to address concerns, provide reassurance, answer questions, and provide referrals (to administration or advocacy as may be indicated). It is inappropriate to have the family confronted by security or threatened to be removed. The nurse may contact security as warranted if the family member becomes threatening. Arranging for the client to be moved out of the hallway is a reasonable compromise if this option is, or becomes, available. Contacting the nursing supervisor is appropriate, but it is unreasonable to insist that the client be transferred immediately.

A client is admitted to the emergency department with a closed head injury after being found unconscious. Based on information from the client's neighbor, the staff suspects intimate partner violence. The client has a restraining order against the spouse, but the spouse repeatedly attempts to visit the client. Which action should the nurse take?

Inform hospital security personnel of the restraining order and description of spouse. The nurse should inform hospital security personnel about the restraining order and formulate an action plan with security that protects the client. The nurse does not have the authority to assign security personnel to be at the client's bedside. Measures should be in place to stop the spouse before he enters the unit, and a sign on the client's door could actually alert the spouse to the client's location. Admitting the client under an assumed name would require the client's consent and additional supervisor approval.

The nurse is assessing a client who is preoperative. The client states, "They got me to sign the consent forms, but I did not really get a chance to ask about some of the risks that I have read about." What is the nurse's best action?

Make contact with the surgeon, and tell them that the client has questions. The nurse can best advocate for the client by making contact with the surgical team so that the client's questions can be answered. The nurse should document, but taking action is the priority. It is not the nurse's responsibility to answer specific questions about surgical risks.

A nurse is working as part of team on the unit on a performance improvement initiative to address a concern that clients are not receiving adequate preoperative teaching. Now that the problem has been identified, which action would the nurse do next?

Meet with the parties involved to develop a strategy. Performance improvement involves four steps: discover a problem (which has already been identified); plan a strategy using indicators based on a meeting with the parties involved; implement a change; and last, assess the change, and if the outcome is not met, plan a new strategy or refocus the strategy to effect change.

A client who has been treated initially in the emergency department for a leg wound from a fall is waiting for care provider evaluation. The client says, "I am tired of waiting, and I am going to leave." The nurse explains that it is important to wait to ensure that there are no other injuries. The client tells the nurse, "I am going to leave. I am not waiting around here any longer. My leg is fine." Which response by the nurse would be most appropriate?

Notify the care provider of the client's intent to leave.

A nurse is reviewing a client's medical record and notes that the health care provider has prescribed furosemide 400 mg orally twice a day. What will be the best action by the nurse?

Notify the health care provider about the concern for the prescribed dose. The nurse is responsible for clarifying any prescription for a medication prescribed outside the normal dose. The usual dose for furosemide is 20 to 80 mg. Therefore, the nurse needs to contact the health care provider to ensure what has been prescribed is indeed correct. There may be a valid reason for the specific dosage prescribed even though it is outside the usual range. Asking the client about the medication is an option, but the nurse needs to confirm the prescribed dose with the health care provider. Although rechecking the formulary for the usual dosage would help to support the nurse's concerns, any prescription that is in question needs to be clarified. Notifying the nurse manager and filing an incident report would not be necessary. It is the nurse's responsibility to clarify the prescription.

A client is being treated in the emergency department for a leg wound and has been impatient about the wait. The nurse explains how the triage process works and the importance of being assessed. The client tells the nurse, "I am not waiting around here any longer. My leg is fine." What is the best response by the nurse?

Notify the healthcare provider of the client's intent to leave. When a client wants to leave a facility, they are legally free to do so, even though such actions carry an increased risk for problems. The nurse has already attempted to explain the importance of staying, so the next step would be to notify the healthcare provider who should then reinforce the need to stay for an evaluation. If the client continues to voice the desire to leave, the client should sign a form that releases the healthcare provider and facility from any legal responsibility for the client's health status. Alerting security is inappropriate. Administering a sedative is inappropriate at this time.

The nurse on a gerontology unit will be admitting several new clients to the unit over the next few hours. There are two shared rooms and one single-client room currently vacant on the unit. Which client should be placed in the single-client room?

a client who has developed hypokalemia due to Clostridium difficile-related diarrhea For reasons of infection control, a client with Clostridium difficile-related diarrhea must be housed in a single room. This infection control measure would supersede the need to accommodate visitors. It is ideal for a client who is agitated to be in a single-client room, but the necessity of infection control would override this factor.

The nurse should monitor evidence-based research and incorporate it into clinical practice and client teaching. When teaching a Hispanic client about an infectious skin condition, the nurse should focus on which factors? Select all that apply.

the level of health care literacy demonstrated by the client; the specific health questions that the client asks the nurse; illness and treatment information specific to the client. The nurse's teaching should be based on professional and evidence-based research. This necessarily includes illness and treatment information that is specific to the client, as well as specific health questions that the client may have. Additionally, the nurse must insure that teaching meets the health care literacy level demonstrated by the client if the teaching is to be fully effective. The client's language is not a direct factor in planning health teaching, and there can be no requirement or expectation that clients are able to access or use online tools such as health care translation services. The use of a facility for primary or supplemental care does not influence client treatment or education.