Emerging Care-Management Issues

A client who survived a hemorrhagic stroke now demonstrates a speech disability. What is the best response when the home care nurse observes the husband speaking for the client and finishing her sentences?

"Although it takes time for your wife to communicate to you and to others, it is important not to speak for her."

A client asks the nurse about antibiotic resistance and how it occurs. What is the nurse's best response?

Overuse and misuse of antibiotics can promote the development of antibiotic-resistant bacteria.

A client has sought care because she has recently returned from a trip to Central and South America and is concerned that she might have contracted the Zika virus. What question should the nurse prioritize during the client interview?

"Is there any chance that you might be pregnant?"

A client is being assessed for multiple lacerations resulting from an assault by an unknown paid sexual partner. The nurse must recognize what as a priority for this client?

The client's safety should be provided in a secure and private environment.

A new diabetic client meets all the criteria to be discharged, but expresses anxiety about being able to manage treatment. What is the best action for the nurse to take? (Select all that apply.)

Review diabetic teaching with the client. Remind the client of self-care in the hospital. Reinforce the client's follow-up appointments.

A client just delivered a healthy baby. The mother wants to put photos on her Facebook page with all the nurses that helped during the birthing process. What is the nurse's response to the client?

"I will have to check with the hospital policy about posting nurses to the Facebook page."

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."

A client has been admitted to the hospital for treatment of kidney stones. The client is allowed a regular diet and is reviewing the menu. 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.

A client returns to the nursing division after a procedure. The client tells the nurse that the client was awake during the procedure and recalls certain events. What is the nurse's priory intervention?

Ask for additional information from the client.

A client hospitalized for a round of chemotherapy reports being very distressed at being unable to sleep because of a series of roommates who have been actively withdrawing from opioids. The nurse responds that they must accept clients who are detoxing from prescribed and illicit drugs. Which action should the nurse take?

Explore difficulties, identify solutions, and negotiate short-term aids.

The nurse is assessing a client with multiple sclerosis who is experiencing mobility problems. What question about diagnostic studies would the nurse ask the client while obtaining the client's history?

Have you had a recent dual-energy x-ray absorptiometry (DEXA) scan?

A female client enjoys wearing men's clothing. Her sister tells the nurse that the client would like to have gender reassignment surgery. The client tells the nurse that she just wants to be left alone. Which nursing intervention should the nurse take first?

Inform the client's sister of medical privacy laws

A client diagnosed with acquired immunodeficiency disorder (AIDS) ten years ago who is now receiving treatment for non-Hodgkin lymphoma asks the nurse, "Why am I getting both chemotherapy and radiation treatments?" What information is important for the nurse to know to answer this question?

Non-Hodgkin lymphoma occurring in clients with AIDS is usually fast growing and both treatments may bring about an initial positive result.

A 4-year-old child is seen in the pediatrician's office. The child is due for immunizations, and the provider discusses with the caregiver the need for the immunizations. The nurse returns to the room to administer the immunizations, and the caregiver refuses to sign the paperwork for the administration of the immunizations. What is the most appropriate action by the nurse?

The nurse listens to the caregiver's concerns and discusses the risks of nonimmunization.

A client who is homeless is admitted for treatment of a severe infection. The client reports, "I'm allergic to everything". The nurse reviews the client's medical records at that facility and learns that the client has extensive identified medication allergies. What is the best action for the nurse to take?

Use the drug allergy listing in the medical record as a starting point for a full allergy assessment.

A nurse manager is working as part of a quality improvement team focusing on catheter-associated urinary tract infection. As part of the risk assessment and infection surveillance program, the team is evaluating the appropriate use of indwelling urinary catheters. The team identifies the need for corrective active when review of the medical records reveals use of an indwelling catheter for which situation?

checking for residual urine in the bladder

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.

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 him or her that the client has questions.

A client was admitted to the coronary care unit (CCU) two days ago with an acute myocardial infarction. Which action would breach client confidentiality?

The emergency department (ED) nurse calls up the latest electrocardiogram results to check the client's progress.

The nurse is performing a prenatal assessment of a client who is in her first trimester. The client states, "I have heard horrible things about the Zika virus and pregnancy. It makes me so worried about my baby." What is the nurse's most relevant assessment question?

"Have you traveled recently?"

A health care provider is legally and ethically required to disclose certain information. Which confidential information should the nurse disclose?

A taxi driver's diagnosis of an uncontrolled seizure disorder to his licensing agency

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 care-giver at home is an adult daughter with a moderate intellectual disability. Which 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.

A nurse admitted a client with ulcerative colitis. A case manager is visiting the client and wants to discuss care. What is the nurse's understanding of the case manager?

The case manager collaborates care among all health care partners with the client in the center.

The client expressed to the nurse that she feels guilt and shame for contracting HIV/AIDS from her ex-boyfriend eight years ago, and although she is feeling well, she cannot develop healthy relationships. What priority action will the nurse implement during the client assessment?

depression screening

The client becomes upset when the nurse asks if the client has an advance directive and states, "Why do I need an advance directive?" What is the most appropriate explanation for the nurse to give this client about an advance directive?

"Let's talk about how an advance directive enables you to have your health care preferences known to your health care providers."

A competent client in a long-term care facility refuses to take his oral diuretic medication. The nurse informs him that if the medication isn't taken, restraints will be applied, and the medication will be given by injection. Which legal tort best describes this nurse's statement?

Assault

A client is admitted for serious complications of poorly managed diabetes. The nurse learns that this client is an undocumented illegal immigrant whose sole income is sporadic day labor. What is the most important action this nurse should take?

Establish rapport with the client to fully assess client needs.

A client recently was involved in a heroin overdose. The prehospital providers administered a reversal agent and performed cardiopulmonary resuscitation. The client has been diagnosed with anoxia and is brain dead. The client's family has just arrived. Which are nursing interventions relevant to the client's condition? Select all that apply.

Find a private room to discuss the client's prognosis. Be prepared to have ancillary staff available such as pastoral care and social work. Allow for viewing of the body.

During nursing orientation, the new graduate nurse notices orientation focusing on preventative services for undocumented workers. Which undocumented ethnic group in the United States will nurses care for the most?

Mexicans

Following surgery, an older adult client was transferred from post-anesthesia unit to the medical-surgical unit of a hospital. An admission assessment was completed by the nurse, then the client was left unattended with the bed in high position and the side rails down. The client falls from the bed. This nurse's action would be considered:

negligence.

Parents of an infant have told the nurse that they have decided not to have their child vaccinated. What is the nurse's best response?

"That must have been a difficult decision. What caused you to make that choice?"

The decision maker for a dying client on hospice care expresses to the nurse that he wants all treatment, including pain medication, stopped to allow for natural death to occur. Based on the principles of palliative care, what is the nurse's best explanation about the plan of care for this client?

"The reason for providing pain medication is to alleviate pain and suffering."

A client with human immunodeficiency virus/acquired immunodeficiency disorder (HIV/AIDS) reports to the nurse that he has lost 15 pounds in the last month and asks, "Do you think that I could use marijuana to help get my appetite back?" What is the nurse's best response?

"There are medications in addition to medical marijuana that can stimulate your appetite and help you to regain weight."

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

"Yes, I completed it after graduation and review it annually."

Which client cannot sign out against medical advice?

A client who drank a bottle of vodka one hour ago

A client is admitted for chemotherapy but insists it be administered peripherally, declining that a PIC line be placed. The client does agree that a line be placed while the client is an inpatient but insists the PIC line be removed at time of discharge. The nurse understands that which intervention(s) are important with this client? (Select all that apply.)

Assess the client's reasons for treatment preference. Respect the client's treatment choice for outpatient care.

A teenage client is to be admitted for a fractured shoulder after being impaled on a fence running away from local police. The nurse learns that the teen lives on the street with surrogate parents. Once the client is assessed and treated, which would be the most appropriate action?

Contact social services to advocate for the teen.

For which signs and symptoms should an adult victim of childhood sexual abuse be monitored? Select all that apply.

Depression Substance abuse Posttraumatic stress

A client with long-term body-focused repetitive behaviors including trichotillomania (hair pulling) finds support through an online website. The client begins to attend local meetings and realizes that a nurse from the clinic also attends. When approached outside of these meetings, how should the nurse respond?

Discuss this to define the relationship.

At the completion of a shift, the nurse is participating in the nursing handoff during the transition from the day shift to the evening shift. At the time of shift change, there are not enough evening nurses to meet mandated nurse-client ratios. What is the nurse's best action?

Document the situation, and remain on the unit until sufficient staffing levels are achieved.

The client who is four days' post-kidney transplantation tells the nurse, "I feel upset about the person who died to give me this kidney." Which goal will the nurse consider to be of primary importance?

Encourage the client to talk openly and express feelings.

A nurse's colleague has posted a video clip to social media of several members of the care team participating in an educational workshop. In portions of the video clip, clients are visible. What are appropriate actions by the nurse? Select all that apply.

Ensure that the colleague takes down the video clip. Remind the colleague about the importance of client privacy and confidentiality.

After being informed that a client is to be admitted to the hospital for stabilization of the client's diabetes, the client's son returns to the hospital six hours later to find that the client remains on a stretcher in the emergency department hallway. He 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.

Which question has been added to nursing admission assessment to screen for the Zika virus?

Have you recently traveled to South America?

A client is admitted to the hospital with a diagnosis of avian flu resulting in acute respiratory failure. What are the nurse's primary goals while caring for this client? Select all that apply.

Prevent deep venous thrombosis. Assess for gastrointestinal bleeding. Monitor for multiple organ failure.

A nurse who has just graduated is caring for a client with a central venous catheter inserted. The dressing on the catheter is scheduled to be changed today. The nurse is uncertain about performing the procedure. Which action would be most appropriate for the nurse to do first?

Review the facility's procedure manual for the steps to complete.

A woman with chronic acquired immunodeficiency disorder (AIDS) tells the nurse at the women's health center that she is sexually active but has not had a gynecological exam for over three years. What important information is essential to include in providing health education for the client?

Safe sex education to prevent the risk of infection

A client is talking to the nurse about the client's new diet of juicing. The client loves the diet but tells the nurse there is a bit of a constipation issue. Which statement is a solution for the constipation?

Supplement the extracted pulp back into the mixture and ingest it.

Over the past 48 hours, a 72-year-old robust client with bacterial pneumonia has developed profuse, watery diarrhea, fever, abdominal tenderness, and loss of appetite. Clostridium difficile infection is suspected. When reviewing the client's chart, which factor would the nurse identify as most likely placing this client at risk?

antibiotic therapy

A student nurse witnesses a registered nurse performing a procedure on a client without obtaining informed consent for the procedure. The student nurse recognizes that the registered nurse is guilty of committing:

assault and battery.

A child admitted to the pediatric ward experiences an adverse reaction to a medication. After reviewing the medical record and speaking with the parents, the nurse identifies that they recently adopted this child from overseas, and there is no available medical history on the child. The nurse's priority action should be to:

assess and monitor the child, document the adverse event, and reassure the parents of the child's safety.

A nurse who is working with a nursing assistant is making care assignments for the shift. Which task would be most appropriate for the nurse to delegate to the nursing assistant? Select all that apply.

checking vital signs documenting oral intake on the I&O;flow sheet assisting with a bed bath for a client who had surgery yesterday

A severely confused client presents over the weekend at the emergency department with acute abdominal pain. The client cannot identify their illness, but reports receiving multiple medicines at the local free clinic each week. The best action the nurse caring for this client can take is to:

complete the physical assessment and inform the physician.

An infection control nurse is reviewing the care of a client diagnosed with Clostridium difficile infection. The nurse determines that the staff is adhering to appropriate infection control precautions based on implementation of which measure?

contact precautions

A client is scheduled for a laparoscopic cholecystectomy and is surprised to learn that he will be discharged later the same day, provided there are no complications. When caring for a client who will be discharged shortly after a procedure, the nurse must:

ensure that health education is begun as early as possible.

A client is undergoing chemotherapy without responding to three different rounds of agents. The client proposes testing for specific serum metal levels based on a review of the history of symptoms and Internet research. The nurse recognizes that the client is demonstrating:

self-advocacy