ELSEVIER _EQA
Which action by the nurse would be priority for a male client with a history of schizophrenia who comes to the emergency department accompanied by his spouse? A) Observing and evaluating his behavior B) Writing a plan of care for the mental health team C)Obtaining a copy of the client's past medical records D) Meeting separately with his wife and exploring why he came to the hospital
A) Observing and evaluating his behavior The priority action is to observe and evaluate his behavior. The client and his needs are the priority, and assessment is the first step of the nursing process. Writing a plan of care for the mental health team is done after a thorough assessment is completed. The nurse must deal with the present, not the past. Although meeting separately with the wife should be done, it is not the priority; it can be done at a later time.
Which member of the interprofessional team in a palliative care setting serves as the client advocate, evaluating the physical, emotional, and spiritual needs of the client? A )Nurse B)Pharmacist C)Music therapist D)Primary health care provider
A )Nurse In a palliative care setting, the health care team would comprise professionals of various disciplines to help achieve care outcomes. The nurse on the interprofessional team evaluates the physical, emotional, and spiritual needs of the client. The nurse also advocates for the client and provides referrals to other members of the team. The primary health care provider assesses the clinical manifestations of the client. The pharmacist supports the care of the client and the needs of the family. Music therapists help increase the comfort of the client.
Which component of delegation is the ability to perform duties in a specific role? A) Authority B) Responsibility C) Accountability D) Legal authority
A) Authority Rationale Authority is the ability to perform duties in a specific role. Responsibility refers to reliability, dependability, and obligation to accomplish work. Accountability determines whether a person's actions are appropriate and provides a detailed explanation of what occurred. Legal authority is the ability to transfer selected nursing activities in a given situation to a competent individual.
Which is the most appropriate approach for the school nurse to take regarding children who are to be given medications while in school? A. Assuring the children that their privacy will be respected B. Teaching each class about taking medications in the school setting C. Encouraging the children to tell their friends that they are taking a medication D. Asking teachers to answer questions when other students ask about medications given in school
A. Assuring the children that their privacy will be respected . Children's and adults' confidentiality is protected by privacy laws. Although health classes may address medication as part of its curriculum, the information should be taught on a general, not a personal, level. Children and their teachers should not be encouraged to divulge private information.
Which type of continuing care should a client expect if discharged home with an infusion device to continue treatment for a leg wound? A. Home care B. Rehabilitation C. Skilled nursing care D. Outpatient therapy
A. Home care Clients who are discharged with an infusion device to continue medication therapy at home should expect home care services to teach appropriate administration of medication therapy in the client's home. The client is being discharged to the home and not to a rehabilitation facility or to a skilled nursing facility. Outpatient therapy is not identified as a method for continuing antibiotic therapy with an infusion device.
A client arrives in the emergency department with multiple crushing wounds of the chest, abdomen, and legs. What are the priority nursing assessments? A. Level of consciousness and pupil size B. Characteristics of pain and blood pressure C. Quality of respirations and presence of pulses D. Observation of abdominal contusions and other wounds
Assessing breathing and circulation are the priorities in trauma management; basic life functions must be maintained or reestablished (ABCs: airway-breathing-circulation). Level of consciousness and pupil size are assessments associated with head injury; in this situation these follow determination of respiratory and circulatory status, which are the priorities. Although blood pressure is an important assessment associated with adequacy of circulation, it is obtained after assessments associated with patency of airway and breathing; a client's pain is addressed after ABC needs are assessed and interventions implemented to support life. Assessment for abdominal injury and other wounds follows determination of respiratory and circulatory status, which are the priorities.
When the nurse revises the care plan because the goals have not been met, which phase of the nursing process is being applied? A) Planning B) Evaluation C) Assessment D) Implementation
B) Evaluation Evaluation includes assessing the client's response to care, judging the effectiveness of the plan of care, and changing the plan as necessary. Planning includes the development of a plan focused on specific goals and actions unique to the client's needs. Assessment entails collecting and reviewing objective and subjective data about the client's health status. Implementation includes performing specific actions designed to achieve the stated goals.
A 17-year-old mother is to sign the consent for her son's myringotomy. Which statement would be most appropriate? A. 'This procedure may not help.' B. 'Tell me what you know about this procedure.' C. 'Your son will need to have this done again when he's older.' D. 'One of your parents must also sign this because you're too young.'
B. 'Tell me what you know about this procedure.' Informed consent requires that the responsible person understand the procedure. Predicting therapeutic outcomes is not within the role of the nurse. Predicting future surgical interventions is not within the role of the nurse. A 17-year-old mother is an emancipated minor who has the legal authority to sign her child's consent form.
Which health care team member is responsible for analyzing the knowledge and work of newly hired unlicensed assistive personnel before delegating a task? A) Charge nurse B) Associate nurse C) Registered nurse (RN) D) Nursing manager
C) Registered nurse (RN) The RN must analyze any individual's knowledge before delegating a task. The charge nurse mainly functions as a liaison between team leaders and other health care providers. The associate nurse follows the care plan in the absence of a RN. The nursing manager is responsible for more than 1 unit and has other managerial responsibilities.
Which health care team member supervises unlicensed nursing personnel (UNPs) in providing care to the client? A)Charge nurse B)Nurse manager C)Registered nurse (RN) D)Patient care associate (PCA)
C)Registered nurse (RN) The RN supervises UNPs and licensed practical nurses (LPNs) in providing care to the client. The charge nurse and the nurse manager may supervise RNs. The charge nurse delegates tasks to the LPN and UNP when the RN does not. The nursing manager is in charge of the RN, LPN, and UNP. The PCA does not supervise UNPs and is delegated tasks by an RN.
An adolescent with terminal cancer tells the home care nurse, "I'd really like to get my general education development (GED) certificate. Do you think that's possible?" What is the best approach for the nurse to take in response to the adolescent's question? A. Refocusing the conversation on things the adolescent has already accomplished in life B. Trying to help the adolescent understand that this goal is too taxing and slightly unrealistic C. Arranging a conference with the school and encouraging the adolescent to prepare for the test D. Suggesting to the adolescent that this energy should be directed toward expressing feelings about the illness
C. Arranging a conference with the school and encouraging the adolescent to prepare for the test Passing the high school equivalency test is the client's desire, and the nurse should do everything possible to help the client fulfill the goal. Refocusing the conversation on things that the adolescent has already accomplished in life is not therapeutic; the client has an unmet need, and the nurse should not try to refocus the client away from the stated objective. The client should be encouraged, not discouraged; mental activity is not too taxing and is not unrealistic if the client wishes to engage in it. There are no data supporting the conclusion that the client needs to work through feelings about the illness
Which action would the nurse take for a client who is a psychologist and has questioned the authority of the treatment team and advised other clients that their treatment plans are wrong? A)Tell the other clients to disregard what the client is saying. B)Ignore the client's disruptive behavior while waiting for it to subside. C)Restrict the client's contact with other clients until the disruptive behavior ceases. D)Accept that the client is unable to control this behavior while setting appropriate limit
Clients who are out of control need to have limits set for them. The staff must understand that the client is not deliberately trying to disrupt the unit. Telling the other clients to disregard what the client is saying is demeaning the client in the eyes of the other clients and does not address the problem directly. Ignoring the client will not stop the disruptive behavior; also, the nurse has a responsibility to the other clients. Restricting the client's contact with other clients until the disruptive behavior ceases may be done as a last resort, but this approach should not be used until other alternatives have been explored.
Which component of delegation is retained while the delegator is delegating the client's care task to the nursing aide? A) Authority B) Supervision C) Responsibility D) Accountability
D) Accountability Accountability is retained by the delegator while delegating a client's care task to the nursing aide. Every individual on the health care team has authority for the delegated task. The nursing aide is only responsible for the delegated task, so the delegator retains the accountability. Supervision is a right of delegation.
Which intervention would the nurse add to the plan of care for a client who engages in ritualistic behavior? A) Redirect the client's energy into activities to help others. B) Teach the client that the behavior is not serving a realistic purpose. C) Administer antianxiety medications that block out the memory of internal fears. D) Help the client understand that the behavior is caused by maladaptive coping with increased anxiety
D) Help the client understand that the behavior is caused by maladaptive coping with increased anxiety The nurse would help the client understand that the behavior is caused by maladaptive coping with increased anxiety. Helping clients understand that a behavior is being used to control anxiety usually makes them more amenable to psychotherapy. Redirecting the client's energy into activities to help others is inappropriate. Treatment includes activities to help the client, not others. The client usually understands already that the behavior is not serving a realistic purpose. Although antianxiety medication can be given, it is not to block out the memory of internal fears. It is to help decrease the anxiety to manageable levels. However, antidepressants have been proven to be more helpful.
A student in high school asks the school nurse why a classmate has been absent for so long. Which is the best response? A. 'Have you asked his girlfriend?' B. 'I wonder why you're so curious.' ' C. Students sometimes miss school for long periods.' D. 'I know you're concerned, but you'll need to ask your classmate for yourself.'
D. 'I know you're concerned, but you'll need to ask your classmate for yourself.' Responding by recognizing the student's concern and indicating that the student needs to ask the classmate directly acknowledges the student's concern while maintaining confidentiality. Asking whether the student has asked the girlfriend does not address the student's concern. Commenting about the student's curiosity is judgmental and does not acknowledge the student's concern. Stating that students sometimes miss school is a general statement that ignores the student's concern.
A 50-year-old male client has difficulty communicating because of expressive aphasia after a cerebrovascular accident (CVA, also known as a "brain attack"). When the nurse asks the client how he is feeling, his wife answers for him. How should the nurse address this behavior? A. Ask the wife how she knows how the client feels. B. Instruct the wife to let the client answer for himself. C. When the wife leaves return to speak with the client. D. Acknowledge the wife but look at the client for a response.
D. Acknowledge the wife but look at the client for a response. The client must have the opportunity to practice language skills; family participation must be accepted and recognized. The spouse should be included and involved in the client's care. Asking the wife how she knows the client's feelings, instructing the wife to let the client answer for himself, and returning to speak with the client when the wife leaves, demeans the spouse and cuts off communication.
Which nursing action has the highest priority when preparing to transfer an unconscious client who sustained a head injury from the emergency department to a neurological trauma unit? A. Notifying the receiving unit of the transfer B. Having the client's records ready for the transfer C. Verifying that the family has been notified of the transfer D. Validating availability of a bag-valve-mask during the transfer
D. Validating availability of a bag-valve-mask during the transfer Validating availability of a bag-valve-mask during the transfer is vital in case of respiratory distress; increased intracranial pressure compresses the brainstem, which contains the medulla, the respiratory center. Notifying the receiving unit of the transfer is important, but not of primary urgency; the respiratory status is the priority. Having the client's records ready for the transfer is important, but not of primary urgency; the respiratory status is the priority. Verifying notification of the family regarding the transfer is important, but not of primary urgency; the respiratory status is the priority.
Which color tag would be given to 'walking wounded' clients according to the disaster triage tag system? Red Black Green Yellow
Green tagged clients are referred to as 'walking wounded' because they may evacuate themselves from the mass casualty scene and go to the hospital in a private vehicle. Clients with life-threatening conditions that need immediate treatment are given red tags. Black-tagged clients are expected to die or may be dead. Clients with major injuries are tagged with yellow. They may require urgent treatment but can wait a short time for care because their injuries are not life threatening.
Which colors are often included in an organizational disaster plan for use during triage? Select all that apply Red Black Green White Yellow
Red / Black / Green / Yellow Colors that are often used for triage purposes in an organizational disaster plan include red, black, green, yellow, and blue. White is not a color that is used during the triage process.