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 spouse speaking for the client and finishing the client's sentences? "Although it takes time for your spouse to communicate to you and to others, it is important not to speak for your spouse." "Remember to use a regular tone of voice when you help your spouse speak so your spouse can clearly understand the answers." "I am wondering if you are concerned about your spouse's cognitive ability, as you seem to frequently speak for your spouse." "Today I noticed that you are speaking for your spouse, and it would be helpful to have practice conversations with your spouse."

"Although it takes time for your spouse to communicate to you and to others, it is important not to speak for your spouse." When a client has a speech disability, it is important to be patient and allow the client time to speak and answer questions, rather than speak for and answer questions directed to the client. The tone of voice does not help the client better understand what is being said. Typical conversations are a part of daily interaction in a relationship, therefore practice conversations are not needed.

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. Notify the nurse manager of the erroneous prescription and complete an incident report. Ask the client about the usual prescribed medication dose and reason for the prescription. Recheck the medication formulary for the usual drug dosage.

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. Alert security immediately about the client's potential exit. Give the client permission to leave at any time. Ask the client if a sedative is needed for relaxation.

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.

A child is admitted for an emergency appendectomy. The grandparents, who are the permanent guardians, do not speak the dominant language. What is the most important way for the nurse to support this family? Transfer the child to a large medical center with translators. Obtain a computer-assisted translator for translation of plan of care. Monitor the child's condition until a translator is located. Ask a hospital employee to help with the surgical consent explanation.

Obtain a computer-assisted translator for translation of plan of care. The nurse will use a computer-assisted translation service to explain the plan of care. Additionally, it may be helpful to locate printed educational information on the disease and treatment that is in both the dominant and the grandparents' primary language. It is inappropriate to consider transferring a child who is in acute need of surgical intervention. It may be unsafe to merely monitor the child's condition until a human translator can be located. Asking employees for assistance is not a safe or effective method of translating nursing or medical information.

The nurse observes a family member of a client who is on contact precautions enter and exit the client's room without performing hand hygiene. What is the nurse's most appropriate action? Document the family member's action, and explain the phenomenon of hospital-acquired infections. Document the family member's action, and move the signage on the client's door to a more conspicuous location. Offer to show family members how to perform hand hygiene using soap and water or hand sanitizer. Inform the family members that they must comply with the client's contact precautions.

Offer to show family members how to perform hand hygiene using soap and water or hand sanitizer. The nurse should address the family member's oversight and promote infection control, but in a way that is nonconfrontational. Offering to show the family members how to perform hand hygiene achieves these goals. Moving signage may not result in a behavior change. Speaking about hospital-acquired infections may not result in improved hand hygiene.

A nurse has discovered a colleague pocketing a partial dose of an opioid despite documenting it as a waste. When confronted, the colleague acknowledges the behavior. What is the nurse's best action? Explain to the colleague that this is a serious violation of policy. Encourage the colleague to seek outside help for substance misuse. Report the colleague's actions because of legal and ethical obligations. Initiate a dialogue with the colleague about the problem of substance misuse among nurses.

Report the colleague's actions because of legal and ethical obligations. Nurses have a duty to report substance misuse among colleagues. It is appropriate to seek solutions with the colleague, but the priority is to ensure that the event is not kept a secret between the two nurses.

A new nurse is asked to present a case study during interdisciplinary rounds on a client who has compartment syndrome from a leg injury. The new nurse is uncomfortable with public speaking. Which action(s) by the new nurse is appropriate? Select all that apply. Suggest that a more experienced nurse be selected to present this case study. Ask to attend the rounds instead of presenting. Approach the unit manager and ask to be excused from presenting. Research the condition, and present what was learned. Review the client's chart to obtain assessment findings and treatment.

Research the condition, and present what was learned. Review the client's chart to obtain assessment findings and treatment. This is an opportunity for new learning about a complication that pertains to the client and an important safety consideration when assessing and performing care measures. Presenting this case would also provide a professional growth opportunity. As a new professional on a unit, it is important to go beyond one's normal comfort zone. Attending rounds will be a learning experience, but not a challenging growth experience. Deferring to a more experienced nurse or approaching the nurse manager demonstrates avoidance of growth opportunities and failure to confront insecurities.

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. Reinforce the client's follow-up appointments. Inform the health care provider to postpone discharge. Suggest the client request a prescription for anxiety. Remind the client of successful self-care already performed.

Review diabetic teaching with the client. Reinforce the client's follow-up appointments. Remind the client of successful self-care already performed. The nurse's best actions are to review diabetic teaching, reinforce the successes the client had in managing care while in the hospital, and remind the client of the follow-up care appointments in place for support. Since the client is anxious, it is important that the nurse recognize reinforcing the knowledge and skills the client has mastered while in the hospital as this will boost client confidence at the time of discharge. Focusing on either the imminent discharge or the presenting anxiety will be counterproductive and nontherapeutic for the client. It is inappropriate to request a prescription for anxiety or to consider postponing the client's scheduled discharge.

A nurse is caring for a client with a central venous catheter who needs a dressing change. The nurse is uncertain about performing the procedure. What action will be most appropriate for the nurse to do first? Review the facility's procedure for the steps to complete. Perform the dressing change as best as possible. Have the nurse on the next shift complete the procedure. Explain concerns about uncertainty to the client during the procedure.

Review the facility's procedure for the steps to complete. The nurse should apply independent problem-solving and clinical reasoning as a first action. This would include reviewing the policy and procedure. It is likely still necessary for the nurse to collaborate with a colleague or manager, but independent problem-solving should be applied as an initial action. Performing the procedure when uncertainty could lead to client injury and sharing the uncertainty with the client is inappropriate.

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 case manager is responsible for all the healthcare choices and all decisions should start with the case manager. The case manager is aware of all needs of the client during the hospitalization and provides for them after the client returns home. The case manager cares for the whole client including the dietary and psychosocial needs.

The case manager collaborates care among all health care partners with the client in the center. Case management is a collaborative process. Case managers work closely with physicians, nurses, social workers, and a wide range of medical and nonmedical professionals. Case managers work to meet complex patient needs. They make provisions for current and future needs of patients. Case management nurses promote quality care that encourages appropriate use of available resources.

The nurse is assessing a client with a history of mental illness who has been brought to the emergency department by first responders. What characteristic of the client's status would most justify involuntary admission? The client lacks social support or a permanent residence. The client has a history of nonadherence to treatment regimens. The client has a longstanding history of major depression. The client demonstrates a serious risk of self-harm.

The client demonstrates a serious risk of self-harm. Involuntary admission is often prompted by an individual's realistic risk of self-harm. A history of mental illness, lack of support, or history of nonadherence would not provide sufficient legal basis for involuntary admission.

A client with a history of major depression established a psychiatric advance directive that was deemed legally valid. The directive specified that the client did not want electroconvulsive therapy (ECT) at any time. The client is legally competent and has expressed a renewed interest in trying ECT. The nurse should anticipate what event? The care team will make a decision based on the client's best interests. The client may revoke or amend the terms of the advance directive. The advance directive may only be overturned by a court order. The client must appoint an individual to have power of attorney.

The client may revoke or amend the terms of the advance directive. During times of legal competency, a client may revoke or amend a psychiatric advance directive. The care team cannot make this decision for the client during times of competency. A court order or the appointment of a person with power of attorney is unnecessary.

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 should be referred to the community free clinic. The client's safety should be provided in a secure and private environment. The client must be tested for sexually transmitted diseases. The client should file a police report as quickly as possible.

The client's safety should be provided in a secure and private environment. Regardless of the gender of the client or the attacker, a traumatic assault demands that safety and security are a top priority. The client may resist filing a police report because of the paid sex (prostitution), and because it was with a stranger. Testing for sexually transmitted diseases is not a priority until the wounds have been treated. The client's illicit behavior does not warrant being referred to a community free clinic.

A client with a terminal illness is unconscious. The client's spouse wants the client's status to be full code. The client's sibling, who is the durable power of attorney and healthcare proxy, insists that the client's status should be do not resuscitate (DNR). Which person has legal precedence? A chaplain should discuss the implications with the spouse and sibling. The sibling's wishes are legally binding. An ethicist should be enlisted to mediate between the spouse and sibling. The spouse's wishes should be honored as the spouse is closest to the client.

The sibling's wishes are legally binding. The durable power of attorney for health care takes legal precedence. It is often recommended that this role be given to someone objectively distanced from the client.

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? Discuss only the most recent drug allergies with the client as these are the most important to know. List only drug allergies on the list that the client can remember having a serious reaction to. Accept the drug allergy listing in the medical record because the client doesn't know what allergies the client has. Use the drug allergy listing in the medical record as a starting point for a full allergy assessment.

Use the drug allergy listing in the medical record as a starting point for a full allergy assessment. It is helpful for the nurse to review the documented drug allergy listing and to use this as a basis for an assessment and discussion with the client. Drugs identified as contributing to an allergic reaction must be recognized and avoided as a serious risk to the client. It is poor practice not to pursue an allergy assessment simply because a client initially reports not being sure exactly what allergies are present; the client may respond well to prompting and an engaged interview. The goal of the nurse is to reach the most complete history and assessment possible with the client. Allergies can occur at any point in treatment, so the most recent allergies do not hold increased importance.

The pediatric nurse is providing care for an infant who has been diagnosed with respiratory syncytial virus (RSV). What action best prevents the spread of this infectious microorganism? Wear a face mask and shield when in close contact with the client. Educate the family about the differences between alcohol-based hand rubs and soap and water. Wear a gown, gloves, and goggles when providing personal care. Administer ribavirin by nebulizer as prescribed.

Wear a face mask and shield when in close contact with the client. RSV infection necessitates droplet precautions, including the use of a facemask and shield. Goggles are not normally included in droplet precautions. It is important to educate family members and visitors about the need for hand hygiene, but the similarities and differences between the two different methods of performing hand hygiene are not a priority. Antiviral medications such as ribavirin are not commonly used, and they do not directly prevent the spread of the infection.

A health care provider is legally and ethically required to disclose certain information. Which confidential information should the nurse disclose? a client who is 32 weeks pregnant with twins and legally separated to the spouse a client's HIV status to family members a taxi driver's diagnosis of an uncontrolled seizure disorder to the licensing agency a client's pancreatic cancer diagnosis to the client's partner

a taxi driver's diagnosis of an uncontrolled seizure disorder to the licensing agency The nurse may lawfully disclose confidential information about a client when the welfare of others is at stake. The nurse is required to inform the Department of Motor Vehicles that the taxi driver has an uncontrolled seizure disorder because it's in the best interest of the public's and client's safety. Confidentiality of HIV testing is required. Disclosing a client's cancer diagnosis to a significant other or pregnancy to a legally separated partner do not affect the welfare of person.

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? age antibiotic therapy immunocompromised status prolonged length of stay

antibiotic therapy Although advanced age, immunocompromised status, and prolonged length of stay are risk factors associated with C. difficile infection, the most likely factor for this client would be the antibiotic therapy used to treat the bacterial pneumonia.

A competent client in a long-term care facility refuses to take oral diuretic medication. The nurse informs the client 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? battery assault autonomy negligence

assault Assault occurs when one person puts another in fear of harmful or threatening contact. Battery is physical contact with another person. Negligence involves actions that are below the standard of care. Autonomy is an ethical principle of self-determination, and does not constitute a legal issue.

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: harassment. assault and battery. breach of confidentiality. neglect of duty.

assault and battery. Performing a procedure on a client without informed consent can be grounds for charges of assault and battery. Harassment means to annoy or disturb someone, and breach of confidentiality refers to conveying information about the client. Neglect of duty is failure to perform care that a prudent nurse would provide under similar circumstances.

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: instruct the parents that their child will be protected and placed in full isolation precautions. assess and monitor the child, document the adverse event, and reassure the parents of the child's safety. contact the physician to request an order for a full allergy panel workup as soon as possible. recommend contacting the adoption agency for the child's birth family medical history.

assess and monitor the child, document the adverse event, and reassure the parents of the child's safety. The nurse's priority remains the safety and care of the child (including documentation), as well as supporting and educating the parents. Recommending that the adoption agency be contacted is a good long-term strategy, but likely would be unproductive on an emergency basis as it was an international adoption. An allergy workup may be helpful on a long-term basis, but the nurse must recognize that allergies can develop at any time in the course of disease or treatment protocol. It is inappropriate to place this child in full isolation precautions based on the available information.

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 action when review of the medical records reveals use of an indwelling catheter for which situation? managing urinary incontinence with sacral pressure ulcer relieving an acute bladder outlet obstruction checking for residual urine in the bladder accurately measuring urine output in a client with multiple trauma

checking for residual urine in the bladder It is inappropriate to use an indwelling urinary catheter to check for residual urine in the bladder; bedside ultrasonic bladder scanning should be used instead. Appropriate uses of an indwelling catheter include cases of acute urinary retention or bladder outlet obstruction, accurate measurement of urinary output in a critically ill patient, and aid in in healing of open sacral or perineal wounds in incontinent patients.

A nurse who is working with a nursing assistant is making care assignments for the shift. Which task would be appropriate for the nurse to delegate to the nursing assistant? Select all that apply. assisting with a bed bath for a client who had surgery yesterday checking vital signs evaluating a client's response to administered pain medication assessing a client's bowel sounds documenting oral intake on the I&O flow sheet SUBMIT ANSWER

checking vital signs documenting oral intake on the I&O flow sheet assisting with a bed bath for a client who had surgery yesterday When delegating client assignments and tasks, the nurse must make sure that the tasks assigned meet the training and educational level of the person to whom the task was assigned. It would be appropriate for the nurse to assign tasks such as checking vital signs, documenting oral intake, and assisting with hygiene measures. Evaluating a client's response to pain medication and assessing a client's bowel sounds are higher level, skilled tasks that the registered nurse must perform.

A severely confused client presents over the weekend at the emergency department with acute abdominal pain. The client cannot identify the 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: obtain and review available medical records on this client. complete the physical assessment and inform the physician. seek hospital staff who have cared for this client previously. review a list of area clinics to contact the treating clinic.

complete the physical assessment and inform the physician. The priority for the nurse remains to provide the best assessment possible, even without recent or remote treatment details. The nurse then should inform the physician of relevant findings. It is helpful to obtain and review available medical records, but this action is in support of the presenting symptoms and assessment by the nurse. Because of the client's confusion, it does not make sense to try to review local clinics in an effort to identify the treating clinic. In all likelihood the clinic will be closed as the client is presenting over a weekend. There is also no guarantee that the presenting symptoms are related to what the clinic may be treating. It is inappropriate to delay care to seek hospital staff who may have provided previous care for the client.

The home health nurse is assessing a client and determines that the client has an unsteady gait. The client reports a history of falls. Which nursing action represents an advocacy role for the home health nurse? contacting a health care equipment resource to rent a walker for the client to use instructing the client to contact a senior day care service listening to a client express feelings of frustration over increasing limitations reassuring the client that using a walker will prevent falls in the future

contacting a health care equipment resource to rent a walker for the client to use Referral to community agencies is an advocacy role for home health nurses. The role of the advocate implies the home care nurse is able to advise clients how to find alternative sources of care. Giving emotional support, giving therapies to clients, and instructing clients about other resources are direct care activities. Reassuring the client is superficial, and using a walker may not prevent falls in the future.

For which signs and symptoms should an adult victim of childhood sexual abuse be monitored? Select all that apply. posttraumatic stress depression enuresis narcissism substance abuse

depression posttraumatic stress substance abuse Childhood sexual abuse is closely linked to the development of depression and substance abuse disorders. It is also linked to the development of somatization and posttraumatic stress disorders. Victims of childhood sexual abuse aren't predisposed to developing narcissistic disorders. Enuresis is frequently seen in children who are victims of childhood sexual abuse. This is typically outgrown as the child ages.

A nurse is working as part of a process improvement team focusing on activities to prevent catheter-associated urinary tract infections (CAUTIs). Which activity would the team most likely address? Select all that apply. documentation of indwelling urinary catheter insertion in clients staff instruction on importance of routine irrigations and cultures educational initiatives for individuals responsible for insertion surveillance related to hand hygiene practices client and family education about insertion and use of indwelling catheters

documentation of indwelling urinary catheter insertion in clients educational initiatives for individuals responsible for insertion client and family education about insertion and use of indwelling catheters surveillance related to hand hygiene practices Process improvement activities related to catheter-associated urinary tract infection (CAUTI) prevention may include documentation of indwelling urinary catheter insertion; training of personnel who insert such catheters; initiation and completion of patient and family education; hand hygiene surveillance; documentation of the necessity for catheterization and a review of its ongoing need; monitoring of insertion techniques; use and maintenance of closed urinary drainage systems; no routine orders for irrigation, cultures, or changing of catheters; and no routine culturing of urine. Facilities should implement evidence-based best practice policies and protocols to prevent CAUTIs.

A nurse is talking with a client who is terminal. The client tells the nurse, "I have a document that says that my child is the one to make decisions about my health care if I cannot. This form should be on my chart." When reviewing the client's medical record related to this discussion, the nurse would most likely find a: living will. durable power of attorney for health care. care provider order for life-sustaining treatment. do-not-resuscitate order.

durable power of attorney for health care. The client is describing a durable power of attorney for healthcare which appoints an agent the person trusts to make decisions in the event of subsequent incapacity. A living will provides specific instructions about the kinds of healthcare that should be provided or foregone in particular situations. Often these may be combined in one document. A care provider order for life-sustaining treatment (POLST) form is a medical order indicating a patient's wishes regarding treatments commonly used in a medical crisis. Because it is a medical order, a POLST form must be completed and signed by a healthcare professional and cannot be filled out by a patient. A do-not-resuscitate order means that no attempts are to be made to resuscitate a patient whose breathing or heart stops. This order is written by the primary care provider in consultation with the family.

A client with diabetes is admitted to the healthcare facility in preparation for colorectal surgery. The nurse determines the client is at increased risk for developing postoperative infection based on what assessment finding? purulent drainage from incision elevated tympanic temperature elevated blood glucose levels elevated white blood cell count

elevated blood glucose levels The nurse is trying to determine the risk for infection, not the presence of a current infection. Elevated blood glucose levels increase the risk for infection. All the other options are evidence of a current infection. Nurses should focus on prevention rather than reaction when possible. Identifying the need to address hyperglycemia could prevent a postoperative infection.

A client is scheduled for a laparoscopic cholecystectomy and is surprised to learn that they 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 this is specified in the client's informed consent document. ensure that the client is safe to drive before being discharged. ensure that health education is begun as early as possible. administer prophylactic antibiotics four to six hours prior to surgery.

ensure that health education is begun as early as possible. Trends towards early hospital discharge heighten the need to begin health education as early as possible and to reinforce it often. Clients cannot drive themselves home safely on the day of surgery, and it is not the nurse's responsibility to review the specific provisions of informed consent documentation. Antibiotics will be prescribed on a case by case basis; their use and the timing of administration will vary.

A nurse is providing care to a client with cancer. The client tells that nurse that the care provider is not giving enough information about the client's condition. Which behavior by the nurse demonstrates advocacy? helping the client create a list of questions to ask the care provider advising the client to suggest a second opinion confronting the care provider about why information is not being shared telling the client the information that the client is asking about

helping the client create a list of questions to ask the care provider Advocacy refers to taking the client's side and supports the client's right to information necessary to make decisions. However, sometimes client advocacy conflicts with the care provider's viewpoint, and the nurse must make sure to maintain a collaborative working relationship with the car provider and not intrude on the care provider-client relationship. In this situation, the nurse demonstrates advocacy by helping the client be assertive by developing a list of questions to ask the care provider. Confronting the care provider would be inappropriate and detrimental to the collaborative relationship. Telling the client the information also violates the care provider-client boundaries and could be detrimental to the collaborative relationship. Advising the client to get a second opinion is inappropriate because it does not address the client's need for information.

A nurse is working as part of a multidisciplinary group of professionals who have been asked to evaluate the facility's recent increase in infections related to central venous catheters. After reviewing the medical records of the clients involved, which activity would the nurse identify as potentially contributing to the increased infection rate? Select all that apply. insertion site dressing changes routinely every 72 hours after insertion use of chlorhexidine-based antiseptic for insertion site preparation client draping from the neck down to the feet for insertion replacement of administration sets at least every 96 hours use of the femoral site for catheter insertion

insertion site dressing changes routinely every 72 hours after insertion use of the femoral site for catheter insertion client draping from the neck down to the feet for insertion According to the Institute for Healthcare Improvement's central line bundle and best practices, the subclavian or internal jugular vein is the recommended insertion site. Additionally, maximum barrier protection should be used for the client, that is, covering the client from head to toe with a sterile drape and leaving a small opening for the insertion site. Chlorhexidine is the preferred antiseptic agent to clean the skin for insertion. Administration sets should be changed at least every 96 hours. However, dressing changes and site care should be done every 5 to 7 days, unless the dressing becomes damp, loose, or soiled.

The nurse leaves an older adult client with confusion unattended with the bed in high position, and the client sustains a fall. What will the action of the nurse be considered? collective liability negligence maleficence battery

negligence Negligence is failure to do what a reasonable, prudent nurse of similar training would do in the same or similar circumstances. It is a general term that denotes conduct lacking in due care. Carelessness is a deviation from the standard of care that a reasonable person would practice in a particular set of circumstances. Collective liability stems from cooperation by several individuals in a wrongful activity, which by its nature requires group participation. Maleficence implies intentional infliction of harm. Battery involves harmful or unwarranted contact with the client.

A home health care nurse is making an initial visit to a 68-year-old client who was recently discharged from a rehabilitation facility after experiencing a stroke. The client has significant left-sided weakness and needs assistance with dressing and hygiene. The client lives alone with a 68-year-old partner. The partner has chronic obstructive pulmonary disease (COPD) and uses oxygen intermittently. Assessment findings include vital signs within normal parameters and intact pink, moist skin. The client denies any problems with urinary and bowel elimination. Based on the client's assessment, the nurse would most likely initiate referrals to which discipline? Select all that apply. speech therapy occupational therapy physical therapy home health aide skilled nursing service

occupational therapy physical therapy home health aide Based on the assessment findings, the client needs assistance with dressing and hygiene. But the client's partner is limited in the amount of care that the partner can provide based on health status. Therefore, a referral for a home health aide would be appropriate to assist in meeting the client's needs. Also, a referral for occupational therapy would be appropriate to assist the client with obtaining a maximum level of functioning related to activities of daily living. The client also has significant left-sided weakness that would benefit from physical therapy. There is no indication that the client needs skilled nursing service or speech therapy.

A client states to the nurse that she feels trapped in her male body and has recently begun to consider gender reassignment surgery. What is the priority intervention for the client? visiting LGBTQ social venues scheduling a consultation with a surgeon telling family and friends participating in psychotherapy

participating in psychotherapy Before having gender reassignment surgery, an individual should receive several years of psychotherapy. If this client has not already done so, establishing a therapeutic relationship with a therapist who is knowledgeable about transition is a priority. The client may wish to tell family and friends of the desire or eventual plan to transition, but the client may want to determine the timing and method of communicating this information in consultation with the therapist. Visiting LGBTQ social venues has no bearing on having gender reassignment surgery. A surgical consult typically isn't scheduled until after the completion of psychotherapy, so this action would be premature.

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 more than 3 years. What important information is essential to include in providing health education for the client? safe sex education to prevent the risk of infection effective partner communication to promote a healthy relationship important health screenings to reduce future bodily injuries ethical decision making to maintain appropriate moral integrity

safe sex education to prevent the risk of infection The essential information to address with the client is that women with HIV/AIDS have a greater risk of contracting sexually transmitted infections such as genital herpes; and they are more likely to have more severe outbreaks than women who do not have HIV/AIDS. Information on the role of effective communication in a relationship, the importance of health screenings, and acting with integrity would be topics for subsequent health teaching sessions.

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. false hope. hopelessness. quackery.

self-advocacy. The client has survived through three rounds of chemotherapy and has now done a health and environmental review to identify a possible complicating factor. Given the presentation, the serum metal levels should be drawn and the ideas should be explored. This client is successfully advocating and demonstrating acceptance of responsibility for a role in the treatment plan. There is no evidence of hopelessness, false hope, or quackery present in the proposal.

A nurse is assessing a client who has had an indwelling urinary catheter in place for the past 4 days. The nurse suspects that the client may have a catheter-associated urinary tract infection (CAUTI). Which finding would support the nurse's suspicion? vomiting suprapubic tenderness mid-epigastric pain temperature 100.2° F (37.8° C)

suprapubic tenderness The CDC's National Healthcare Safety Network (NHSN) has established criteria for classifying a urinary tract infection as a CAUTI. The first criterion to be met is that the client has had an indwelling urinary catheter in place for more than 2 calendar days (day 1 being device placement while in the hospital); the device was in place on the day of onset of a UTI; and the presence of at least one of the following: temperature greater than 100.4° F (38° C), suprapubic tenderness with no other recognized cause, and costovertebral angle pain or tenderness with no other recognized cause. In addition, the client must have a positive urine culture containing no more than two species of microorganisms at least one of which is a bacterium of 105 colony-forming units (CFUs)/mL or more. Candida species are no longer considered urinary pathogens. A temperature of 100.2° F (37.8° C), mid-epigastric pain, and vomiting are not criteria for CAUTI.

A nurse is working on a unit that is short staffed for the shift and is delegating client care to a licensed practical nurse. Which activity would be appropriate for the nurse to delegate? Select all that apply. education about how to administer a heparin injection to a client diagnosed with deep vein thrombosis assistance with range of motion exercises for a client diagnosed with Alzheimer's disease assessment of a client who has just returned from the postanesthesia care unit administering a sitz-bath to a client who has had perineal surgery 2 days ago vital sign monitoring of a client who is 3 days postsurgical repair of a fractured hip

vital sign monitoring of a client who is 3 days postsurgical repair of a fractured hip assistance with range of motion exercises for a client diagnosed with Alzheimer's disease administering a sitz-bath to a client who has had perineal surgery 2 days ago The nurse, when delegating tasks, needs to keep in mind the scope of practice for the licensed practical nurse (LPN). Vital sign monitoring, assistance with range of motion exercises, and administering a sitz-bath are within the scope of practice for an LPN. The LPN can collect or gather data and reinforce teaching, but the assessment and education are outside the LPN's scope of practice.

A nursing student is assigned to care for a client with HIV. The student asks the staff nurse what precautions are necessary when measuring this client's blood pressure. What is the best information to give the student? wash hands use contact precautions wear a gown wear gloves

wash hands Because measuring blood pressure doesn't involve contact with the client's blood or secretions, the nursing student should wash the hands before proceeding.

After being evaluated for donating a kidney to a child, a client asks the nurse, "Why wasn't I a perfect match for my child?" What is the nurse's best response to this question? "Although you are the parent, you were not a compatible donor because of antigens in your child's blood that reacted to antigens in your blood." "Sometimes a parent or other blood relative is not of the same blood type, and this can prevent you from being an eligible kidney donor." "The important thing to remember is that if one parent is not a compatible match, then the other parent can be tested and become the potential donor." "It is rare to have a perfect match among family members; even parent and child matches can be incompatible, and this happens in all families."

"Although you are the parent, you were not a compatible donor because of antigens in your child's blood that reacted to antigens in your blood." Even when a donor and recipient have the same or a compatible blood type, there are often recipient antigens that react adversely to the donor's cells. This indicates that a kidney would be immediately rejected, and therefore it would not be transplanted. The blood type can be the same or compatible for a donor to be eligible to be tested. It is the antigens that need to match for a transplant to be successful. It is not appropriate for the nurse to recommend to one parent that the other parent be tested as a potential donor. The term "perfect match" is not an accurate term to use to describe compatibility. Often family members are incompatible and a cadaver donor is needed. Antigen testing refers to obtaining suitable matches where the recipient and donor are compatible.

A visitor asks the nurse about entering the room of a client who has contact precautions for methicillin-resistant Staphylococcus aureus (MRSA). The nurse explains the necessary precautions needed to visit the client. What statement by the visitor reflects understanding of the contact precautions teaching? "The mask will decrease the risk of my friend spreading MRSA." "I will wash my hands after I go in the room and if I touch anything in my friend's room." "By using gowns, gloves, and washing my hands, I will decrease the spread of MRSA." "The use of these masks and gloves will decrease the risk of me getting MRSA."

"By using gowns, gloves, and washing my hands, I will decrease the spread of MRSA." Contact precautions for MRSA require gloves and gowns. A mask does keep respiratory secretions in isolation, but the client has MRSA and is on contact precautions. The visitor should wash hands before the visit and after the visit to decrease the spread of the MRSA.

A child has been brought to the emergency department by child's grandparent. The grandparent tells the nurse, "It is important that the child's parents not know the child is here. The child lives with me, and they are no good for the child." What is the nurse's most relevant assessment question? "What kind of risk do the child's parents pose?" "Do you have legal custody of the child?" "Is there a realistic chance they know the child is here?" "What can we do to best ensure the child's safety?"

"Do you have legal custody of the child?"' In addition to enlisting other members of the care team, the nurse must know whether the grandparent has legal custody of the child or if the parents still have custody. This information must be known in order to manage this situation and before the other assessment questions can be addressed.

A nurse is teaching a client about simple wound care. The client insists on using a smartphone to record the procedure. What is the nurse's best response to the client? "That is a great idea then you will know how to do the wound care." "After you record the video, are you going to post it to the Internet?" "I will need to clarify with my manager if you can record the procedure." "There are many Internet sites that can serve as a resource for you."

"I will need to clarify with my manager if you can record the procedure." The use of technology and use of social media should be reviewed with the client. The institution may have a policy regarding the method of discharge instructions for liability purposes. Posting the video to the Internet may be considered a violation of the nurse's privacy if a voice or physical appearance is visible. Suggesting that any Internet site can provide information is not safe for the client's wound care needs. A reputable, evidence-based site should be used. The nurse should not confirm the idea about taping a procedure until the facility approves the use of the client's technology.

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? "Were you vaccinated against the Zika virus before you left on your trip?" "How would you describe your overall level of health before you left?" "Were you ever on a farm or ranch when you were on your trip?" "Is there any chance that you might be pregnant?"

"Is there any chance that you might be pregnant?" Infection with the Zika virus is associated with an increased risk of microcephaly. There is no vaccine, and it is spread by mosquitos; being on a farm or ranch is not a risk factor. The client's overall level of health is important during any assessment, but this is not directly related to the possibility of Zika virus infection.

The client who is being prepared for kidney surgery asks the nurse, "Why didn't the surgeon remove my old kidney to make room for the new kidney?" What is the nurse's best response to this question? "The kidney is inserted into the abdomen and there is space for it among the body's other organs." "The removal of the old kidneys is a joint decision made by both the client and the transplant team." "Since the old kidneys are not functioning, they shrink in size and this allows space for the new kidney." "It is not necessary to remove the old kidneys as the new kidney will be transplanted into the abdomen."

"It is not necessary to remove the old kidneys as the new kidney will be transplanted into the abdomen." The kidney is transplanted into the abdomen where the renal artery is sutured to the iliac artery for maintenance of a strong blood supply and the ureter is sutured into the urinary bladder. The placement of the new kidney depends on establishing a strong vascular connection, not about finding or making space for it. There is usually no need to remove the old kidneys and no decision between the client and surgeon typically occurs. In a rare case, chronic infection in the old kidneys may be an indication for their removal. Although it is true that kidneys can shrink in end-stage renal disease, this condition has no effect on transplanting the new kidney into the abdomen.

During a prenatal visit, the client has told the nurse that she intends to give birth at a spiritual retreat center that is distant from population centers or healthcare facilities. What is the nurse's best response? "That sounds fascinating, but have you given thought to what would happen if you had complications during or after delivery?" "That is very exciting. Has your care provider given permission for you to pursue that?" "It sounds like you have given this a lot of consideration. What is it about giving birth there that will be special for you?" "More and more women are choosing birth plans that do not involve being at a hospital."

"It sounds like you have given this a lot of consideration. What is it about giving birth there that will be special for you?" Asking about what the woman hopes to gain or experience is an empathic and therapeutic way of initiating dialogue about this client's decision. Offering a warning will likely sever any follow-up discussion. Ultimately, clients do not need permission to enact a care plan. Acknowledging that nonhospital births are increasingly common is appropriate, but it is helpful to follow a statement with a question.

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? "The advance directive allows your health care team to provide optimal health care under any circumstances that happen to you." "An advance directive is all about living well and having your specified treatment plans followed by your primary care physician." "In all situations the advance directive allows you to appoint other people to decide what the best end-of-life care is for you." "Let's talk about how an advance directive enables you to have your health care preferences known to your health care providers."

"Let's talk about how an advance directive enables you to have your health care preferences known to your health care providers." The client's statement indicates a need to learn the purpose of an advance directive (which is to have the client's health care preferences made known to the health care providers). Inviting clients to talk about making decisions and stating their wishes about end-of-life care and health care treatment enables the clients to discuss what is important and culturally appropriate to them. An advance directive does not ensure the arrangement of ideal or optimal care in all medical circumstances, but assists the client to select desired care and a health care proxy. It gives the clients a voice in decision making and establishes that their wishes will be followed.

A school-age child is injured while playing, and the grandparent who is the legal guardian is notified. The biological parent arrives at the hospital first. How will the nurse respond to the biological parent's request for information about the child's condition? "If you have proof of your relationship, I can provide you with information." "I can provide you with information about the injury and treatment plan." "Once the child's legal guardian is here, you may request information from them." "You have lost the right to be involved in your child's healthcare decisions."

"Once the child's legal guardian is here, you may request information from them." The legal guardian is the person responsible for the child and for making decisions regarding the child. Information about the child should be shared with the legal guardian, who can then choose whether to share with the biological parent. Proof of the relationship does not change the legality related to guardianship. The nurse should not say the parent lost the right to be involved in the child's healthcare, because it is judgmental and offensive.

A nurse's coworker tells the nurse, "I am not going to get this year's flu vaccination. Last year I felt sick right after I got it." What is the nurse's best response? "It is our responsibility as healthcare providers to keep vaccinations up to date." "Reducing your own risk of getting influenza ultimately benefits your clients." "I hope you change your mind. I am sure it was just coincidence that you did not feel well after getting it last year." "If you could guarantee that you will not get influenza for a year, why would you not do it?"

"Reducing your own risk of getting influenza ultimately benefits your clients." Framing the issue in terms of benefiting clients is likely more effective than making a declaration about professional responsibility. Influenza vaccinations do not confer 100% protection against the disease.

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? "That is ridiculous. You should never trust anything you read on the Internet." "That is interesting, but you know, a brain tumor is really not a possibility." "Tell me more about where you found this information that you gave me." "Let us contact your primary care provider about this information."

"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.

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? "Is there any information we could give you that could change your mind about vaccination?" "I understand. There are certainly risks associated with vaccination that many parents are not comfortable with." "It is in your child's best interests to be vaccinated since it can prevent many very serious illnesses." "That must have been a difficult decision. What caused you to make that choice?"

"That must have been a difficult decision. What caused you to make that choice?" Rather than immediately trying to dissuade the parents from their decision, the nurse should engage them in a dialogue about their particular concerns and questions about vaccination. At the same time, the nurse should avoid characterizing vaccination as a high-risk action. The nurse should engage the family in a way that prompts further discussion.

A client diagnosed with cancer tells the nurse about wanting to stop treatment and die at home. The healthcare team suggests another round of chemotherapy. What statement by the nurse to the healthcare team best reflects client advocacy? "The client has expressed not wanting to pursue additional treatment." "I think chemotherapy may be more harmful for the client than no treatment." "I believe that the client has something to offer to the treatment plan." "Can we discuss treatment options for the client other than chemotherapy?"

"The client has expressed not wanting to pursue additional treatment." The nurse acts as an advocate by directly discussing the client's wishes with the team. The nurse needs to be an advocate, especially after learning earlier about the client's desires. Sharing the client's input is part of advocacy, but disclosure of the client's wishes to go home must be explored. Questioning the team's plan is not as direct a form of advocacy as pointing out that the client wishes to discontinue treatment. The nurse may open the conversation with other options, but the question does not address the client's wishes.

Parents bring a newborn to a well-child check-up and tell the nurse they are concerned about the safety of vaccinations due to a link to autism spectrum disorders. What response by the nurse would be most appropriate? "Autism spectrum disorders are a genetic problem and not caused by vaccines." "The concerns with autism spectrum disorders from vaccines are not well supported by research." "I will tell your pediatrician about your wishes so we can plan your visit." "I have never heard of any cases of autism spectrum disorders occurring from vaccines."

"The concerns with autism spectrum disorders from vaccines are not well supported by research." According to the Centers for Disease Control and Prevention (CDC), there is no link between vaccines and autism spectrum disorders, and no evidence exists to support the thinking that vaccine ingredients cause autism spectrum disorders. The parents evidently have concerns, and the nurse needs to address the concerns by providing information about the safety of vaccines. Telling the parents that autism spectrum disorders are a genetic is not helpful to support vaccination. Telling the parents that the nurse has not heard of any cases of autism spectrum disorders occurring from vaccines is inappropriate and does not address the concern or allow for further discussion. Telling the parents that the nurse will inform the pediatrician is inappropriate because it reinforces the misconceptions.

The decision maker for a dying client on hospice care expresses to the nurse that all treatment, including pain medication, should be 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 appropriate method for allowing natural death is to no longer administer fluids." "The interventions being provided do not prevent natural death from occurring." "The reason for providing pain medication is to alleviate pain and suffering." "The usual end-of-life treatment options are being done as ordered by the health care provider."

"The reason for providing pain medication is to alleviate pain and suffering." The care provided to allow natural death is based on patient comfort and pain management instead of extension of a person's life. Thus, the management of pain, as well as other symptoms, is the established strategy for managing humane and evidence-based palliative care. Since this is the rationale for providing the treatment, this is the best response to the decision maker's concern. A statement that the interventions do not prevent natural death is an assertion that contradicts the decision maker's stated concern, but it does not a supporting rationale and it is unlikely to address the root concern of the decision maker. The administration of fluids can be a comfort measure and does not prevent natural death. Stating that the health care provider's orders are being followed does not give the decision maker adequate information about humane care of the dying.

A client who has experienced an incomplete spinal cord injury participated in therapeutic horseback riding during the rehabilitation experience. What is the nurse's best response to the client's question, "Why should I continue to do this therapy after discharge?" "There are well-established physical and emotional benefits for you from continuing the horseback riding." "Usually the clients who continue this therapy feel good and are motivated to participate in other exercises." "It gives pleasure to people who need to have positive things to do and it may prevent depression." "It promotes a sense of security."

"There are well-established physical and emotional benefits for you from continuing the horseback riding." There is a physical and psychosocial benefit from engaging in therapeutic horseback riding with clients who experienced a spinal cord injury. Therapeutic horseback riding has been documented to increase muscle strength, improve balance, and promote a positive sense of self. It is not known if horseback riding motivates clients to engage in other activities, prevents depression, or promotes a sense of security that is often seen in clients with companion animals.

The nurse has taught the partner of a client who experienced traumatic vision loss strategies for effectively interacting with the spouse. Which statement by the partner indicates that the health teaching was successful? "When my spouse refuses to let me guide him, I remind him that I want to keep him safe." "The one thing I have remembered to do is to have my spouse sit down before I do." "I decided to make arrangements to obtain a service dog for my spouse." "Today I used the clock suggestion to state where things were located in the room."

"Today I used the clock suggestion to state where things were located in the room." If the partner is giving directions by using clock cues, then the teaching has been effective. When the partner unilaterally makes decisions like deciding to obtain a service dog, determining that the spouse must be seated first, and insisting on guiding the spouse rather than just offering assistance, then the nurse recognizes that additional teaching is necessary.

A client who likes energy drinks asks the nurse if consuming bread or milk will reverse the effect of excessive caffeine intake. What is the best response by the nurse? "The bread must be soaked in milk to be effective." "Any milk you drink must be diluted with water." "Do an internet search on how to reduce caffeine." "Water is the safest way to keep the body hydrated."

"Water is the safest way to keep the body hydrated." The nurse must recognize this as a teaching opportunity and be diplomatic in the response. Water is a basic tool to serve to hydrate. Neither diluting milk with water nor soaking bread in milk is recommended as a treatment for excessive caffeine intake. Suggesting an internet search is avoiding the teaching opportunity and may not provide appropriate results.

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? "I plan to do it when I can find the time to do it correctly." "It was a required document during my military service." "I'm single and healthy, so I don't need one at this time." "Yes, I completed it after graduation and review it annually."

"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 is being treated for a bacterial infection with intravenous antibiotics that are prescribed for 5 days. On the fourth day of treatment, the client states they must leave the hospital to care for a cat at home. What is the nurse's best response? "I don't agree with your choice. Your animals should not be more important than your health." "You're almost done with treatment, so we can safely send you home with oral antibiotics." "You have a right to leave, but I want to teach you about possible complications first." "I have a friend who has a pet-sitting business. Would you like me to get you the number?"

"You have a right to leave, but I want to teach you about possible complications first." The client does have the right to leave against medical advice (AMA). Imperative to AMA, the nurse should counsel the client regarding the potential complications related to the discharge. The nurse should not recommend a friend's business to the client or tell the client their choices are wrong. The nurse cannot make the decision to switch the client to oral antibiotics earlier than prescribed.

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 low in fruits promotes higher glycemic control. A diet high in protein may strain the kidney function. A diet low in fat reduces cholesterol. A diet high in carbohydrates may increase insulin production.

A diet high in protein may strain the kidney function. High-protein, low-carbohydrate diets like the Atkins diet have been widely promoted as effective weight loss plans. The diet also allows for a high fat intake. The complications associated with this diet include high cholesterol, kidney problems, and osteoporosis.

A child is brought into the emergency department with a severe asthmatic episode by the grandparents who are caring for the child over the weekend while the parents are away. What is the legal consideration(s) for the health care team? Select all that apply. The child needs to have an advance directive to guide treatment. Treatment cannot be initiated without the parents' written permission. A medical power of attorney signed by the parents is acceptable for the grandparents to seek treatment for the child. Treatment can be initiated with parental consent by telephone. Severe asthmatic episodes can be life-threatening and must be treated immediately.

A medical power of attorney signed by the parents is acceptable for the grandparents to seek treatment for the child. Treatment can be initiated with parental consent by telephone. Severe asthmatic episodes can be life-threatening and must be treated immediately. The nurse should acknowledge that the need to address life-threatening conditions should take priority over legal or administrative tasks. A medical power of attorney for the grandparents signed by the parents is an acceptable substitution for parental permission within the parameters of the signed document. However, even in the absence of a valid power of attorney, delaying emergency treatment until the parents can be reached is unacceptable practice. Parental consent can be done by telephone. Necessary permissions could be obtained as soon as the responsible party can do so. Children do not have advance directives unless parents have created an advanced directive on behalf of the child. Advanced directives are not needed in this case.

A nurse is preparing a 24-hour-old baby boy for circumcision. The hospital policy guidelines for circumcision support pain medication at least 1 hour prior to the start of the procedure. The provider did not order the pain medication. The provider arrives, and the nurse refuses to bring the baby for the circumcision stating that the pain medication was not ordered. Which is the rationale for refusing to bring the baby for the procedure? A nurse can refuse and request another provider to perform the procedure because of inadequate prep. A nurse can refuse until the order requiring premedication is changed. A nurse is allowed to refuse orders only if another nurse can attest that the order is dangerous to the client. A nurse has a right to refuse orders that might be harmful to the client.

A nurse has a right to refuse orders that might be harmful to the client. The nurse does have a right to refuse orders that might be harmful to the client. The nurse practice act of each state governs the practice of nursing. Each nurse should have a copy of the state practice act, the regulations, and any other official documents governing nursing practice for each state where the nurse is employed. All of these documents define the legal scope of nursing practice and guide and protect nurses in performing their duties.

The nurse is assessing a client who is distraught after receiving a positive diagnosis for human immunodeficiency virus (HIV). The client states, "I am not ready to die." What is the nurse's best action? Offer empathy to the client, and ask permission to arrange a referral for palliative care. Educate the client about the fact that HIV is often curable with current antiretroviral regimens. Acknowledge the client's fears, and then explain the increasing survival times in HIV. Arrange for the client to speak with the primary care provider in order to discuss the prognosis.

Acknowledge the client's fears, and then explain the increasing survival times in HIV. Individuals with HIV are now living up to several decades after diagnosis. In many cases, HIV has the characteristics of a chronic illness. It is not curable, however, and the primary care provider may not be the most appropriate person to meet the client's needs during this crisis. A palliative care referral would be premature.

During a routine follow-up clinic visit, the client with stable human immunodeficiency virus/acquired immunodeficiency disorder (HIV/AIDS) stated, "I just don't eat much anymore." What significant information is most important for the nurse to obtain during the assessment? Obtain information about the time of day the client eats and about meal preparation. Identify if the client eats alone or has someone to eat with on a regular basis. Address personal and environmental factors that interfere with the client's food intake. Determine the specific meal plans the client was instructed to eat when first diagnosed.

Address personal and environmental factors that interfere with the client's food intake. By assessing the personal and environmental factors that interfere with the client's eating, the nurse can develop interventions to address specific problems. The other information such as eating times, preparing meals, following specific meal plans, sharing a meal with others, or eating alone can reflect the client's personal preferences. The most significant issues to assess are the client's personal problems and environmental barriers.

A client has been admitted for a scheduled bunionectomy. The client has presented the nurse with a detailed interdisciplinary care plan based on internet research that the client has conducted. What is the nurse's best initial response to this client? Compare and contrast the client's care plan with standard preoperative care. Educate the client about the fact that the care team normally creates the care plan. Affirm the client's efforts to engage in their healthcare. Assess the client for potential nonadherence to prescribed treatments.

Affirm the client's efforts to engage in their healthcare. The nurse can best establish a therapeutic relationship with the client by providing affirmation. This will lay a productive foundation for discussing the client's care.

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? Social work support has been established for the caregiver. The insurance company is aware of the need for increased services. An immediate home visit is arranged with the visiting nurse service and the social worker. Physical therapy service has been coordinated in the 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.

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. Administer the influenza vaccine. Provide oxygen via nasal cannula. Assess for gastrointestinal bleeding. Monitor for multiple organ failure.

Assess for gastrointestinal bleeding. Monitor for multiple organ failure. Prevent deep venous thrombosis. The nursing goals are to monitor for changes in the client's condition and focus on the prevention of complications such as deep venous thrombosis, gastrointestinal bleeding, and deterioration of the major organs resulting in multiple organ failure. There is no vaccine available for avian influenza. Supplemental oxygen is required for successful management of this illness; however, ventilation support is required rather than oxygen via nasal cannula.

A client is admitted to the hospital for ongoing chemotherapy but insists it be administered peripherally, declining a peripherally inserted central catheter (PICC) insertion. What action(s) will the nurse perform with the client? Select all that apply. Inform administration that the client is refusing necessary care. Reinforce the need for strict hand hygiene in the hospital. Respect the client's treatment choice for care. Assess the client's reasons for treatment preference. Advise the client of increased risk of developing infections.

Assess the client's reasons for treatment preference. Respect the client's treatment choice for care. Reinforce the need for strict hand hygiene in the hospital. The client is having ongoing chemotherapy. The nurse should assess reasons for wanting to continue peripheral chemotherapy and acknowledge the client's declination of a PICC line. The nurse will need to continue teaching about infections and the need for strict hand hygiene remains the same in or out of the hospital and regardless of which venous access is used. The nurse does not need to notify administration about refusal of care because the client is having chemotherapy peripherally. The health care provider prescription needs to reflect site of method of delivery.

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? Long-term use of antiretroviral agents protects against cardiovascular disease. Emergency cardiac drugs are contraindicated in clients taking antiretroviral agents. Chronic HIV clients are at increased risk for cardiovascular disease. Most clients treated long-term for HIV are also chronic smokers.

Chronic HIV clients are at increased risk for cardiovascular disease. The nurse should recognize that a long-term HIV-positive client is at increased risk for many chronic conditions, including cardiovascular disease and myocardial infarction. HIV causes chronic inflammation that can contribute to cardiovascular disease. Some antiretroviral medications are associated with insulin resistance and hyperlipidemia, thus increasing the risk of cardiovascular disease. It is judgmental to assume that this client is a smoker because of the HIV diagnosis. It is not true that either antiretroviral agents protect against cardiovascular disease or that emergency cardiac drugs are contraindicated in clients taking antiretroviral agents.

The nurse assesses a client with a fever and a draining arm wound. The healthcare provider suspects a methicillin-resistant Staphylococcus aureus (MRSA) infection and issues orders. What health care provider order will the nurse implement first? Teach the client wound care. Administer acetaminophen for the fever. Cleanse the area around the wound, and obtain a culture. Initiate a consult for a surgical debridement.

Cleanse the area around the wound, and obtain a culture. The nurse needs to obtain a culture after cleansing the area around the wound. The administration of the acetaminophen is not a priority. The wound care treatment may change as treatments continue, so teaching is not a priority. The surgical consult is important, but the culture needs to be obtained for MRSA confirmation.

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? Notify the police that the client is being released. Have security escort the client out of the hospital. Arrange visiting nurse services for follow-up care. Contact social services to advocate for the teen.

Contact social services to advocate for the teen. As this client is a minor, is living on the streets with a "found family," and was running from the police, social services is the appropriate first point of contact to advocate on the teen's behalf and coordinate with necessary resources. Based on the information presented, it is inappropriate to notify the police. There is no information suggesting that hospital security should be involved or that the teen must be escorted from the facility. Arranging visiting nurse services is unhelpful as the child has no fixed abode; it might be helpful to refer the client to a community clinic or mobile clinic.

A newly-admitted client has told the nurse, "I always take a thyroid pill each morning but I do not think I have been prescribed it here in the hospital." The nurse confirms that the client's medication orders do not include this. What is the nurse's best action? Contact the client's provider, and discuss the fact that the client normally takes thyroid supplements. Document the client's statement in the health record, and assess for signs of hypothyroidism. Explain that the body stores sufficient thyroid hormone for two to three weeks. Ask the client if there is a family member who can bring a supply of the medication from home.

Contact the client's provider, and discuss the fact that the client normally takes thyroid supplements. The nurse's priority action is to make the provider aware of this potential oversight. Family members should not bring medications that have not been prescribed in the hospital. Thyroid supplements should be taken daily.

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? Pretend not to know the client. Stop attending this support group. Let the client establish the rules. Discuss this to define the relationship.

Discuss this to define the relationship. Social media and self-help groups can contribute to blurred boundaries between personal and professional relationships. The nurse should take the lead to discuss boundaries with the client. This means that the relationship needs to be defined. Generally letting the client do this fails as the client does not understand the conflict and responds positively to having contact with the nurse outside of the professional setting. Pretending not to know the client can be hurtful, while leaving the group can be detrimental to the nurse.

An older client must be admitted for a serious respiratory condition, but resists all recommendations to do so. A nurse is able to learn that the client has an unauthorized pet cat at home that must be cared for. What is the best action for the nurse to take? Disregard this information as it is not related to the illness. Have the fire department rescue the cat from the apartment. Discuss with the client ways to find a temporary caretaker. Notify the landlord to take the unauthorized cat away.

Discuss with the client ways to find a temporary caretaker. The client cannot focus on admission, treatment, and healing until safe arrangements are made to care for the pet. Contacting the landlord would mean loss of the pet as well as possible conflicts with staying in the apartment. Contacting the fire department may mean the loss of the pet as well as incurring additional expenses, which would be an added burden. Disregarding client concerns would be nontherapeutic.

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 number of nurses on the unit at shift change before leaving the unit. Document efforts to find short-term replacement staffing before leaving the unit. Document the situation, and remain on the unit until sufficient staffing levels are achieved. Temporarily delegate nursing care to unlicensed care providers.

Document the situation, and remain on the unit until sufficient staffing levels are achieved. In order to avoid abandoning clients, the nurse is required in most jurisdictions to remain on the unit until safe staffing levels are achieved. Careful documentation is necessary during all stages of such a transition.

The client who is 4 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? Assess the client for feelings of guilt related to the surgery. Encourage the client to talk openly and express feelings. Teach the client to use exercises as a distraction from anxiety. Discuss the client's personal concerns about death and dying.

Encourage the client to talk openly and express feelings. It is important for the client to discuss concerns and to express feelings related to the person whose kidney was donated. The nurse's primary goal is to maintain open communication and encourage the client to address feelings and concerns. The client may be experiencing grief related to the loss of the donor's life. The expression of feelings will assist the client to cope with them rather than to dwell on negative feelings like guilt. Distractions can provide temporary respite from the anxiety felt. However, it is more therapeutic to have the client express and manage current feelings. The discussion of the client's concerns about death and dying may be something to address in a future conversation.

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? Contact the nursing supervisor to insist that this client is transferred immediately Ensure the comfort and security of the client and meet privately with the family member. Contact hospital security to arrange for the removal of the disruptive family member. Contact the receiving unit to expedite the transfer process.

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 for serious complications of poorly managed diabetes. The nurse learns that this client is an undocumented immigrant whose sole income is from sporadic day labor. What is the most important action this nurse should take? Contact security so they can alert the immigration authorities. Establish rapport with the client to fully assess client needs. Notify a social worker who can make housing referrals. Inform the nursing supervisor so the client can be discharged.

Establish rapport with the client to fully assess client needs. The nurse's responsibility is to treat the client, and this should begin with establishing a therapeutic relationship and conducting a complete nursing assessment. It is inappropriate to discharge the client, report the client to immigration, or involve social workers at this point.

A client is on isolation precautions for a hospital-acquired infection, and the client's visitors are not following the posted hand hygiene protocol. What is the nurse's best action? Document this for the insurance company to bill the client. Post "do not enter" and "report to the nurse's desk" signs on the hospital door. Report this to the healthcare provider to request an order restricting visitors. Explain to visitors the importance to the client of consistent hand hygiene.

Explain to visitors the importance to the client of consistent hand hygiene. The nurse should teach the client and visitors of the need to practice consistent hand hygiene. Hand hygiene by visitors reduces the risk of adding a secondary infection being transmitted to the client. Requesting visitor restrictions and contracting the insurance company are inappropriate actions. Posting "do not enter" signs brings attention but is not the most important action.

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? Place the client in a room near the nursing station with a sign on the door restricting visitors. Inform hospital security personnel of the restraining order and description of spouse. Assign security personnel to be at the client's bedside at all times. Admit the client to under an assumed name and post sign on door restricting visitors.

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 has answered the telephone at the nurses' station, and the individual on the line states that there is bomb in the healthcare facility. What is the nurse's best response? Hang up the telephone immediately, and instruct a colleague to call 911 promptly. Keep the individual on the line in order to gather more information about the details of the threat. Inform the authorities, and begin evacuating clients and closing doors. Hang up the telephone, and use the overhead paging system to call all staff to the nurses' station.

Keep the individual on the line in order to gather more information about the details of the threat. If a bomb threat is received, the nurse should keep the caller on the line and talking as long as possible in order to gather information about the location of the bomb and a description of the bomb and the caller. The threat must be reported promptly, but the nurse should not hang up in order to do this.

A nurse is using the computer for documentation when a client calls for pain medication. What is the best action by the nurse? Leave the computer terminal with entry open to complete documentation and administer the pain medication. Ask another nurse to administer the pain medication. Ask the unlicensed assistive personnel (UAP) to inform the client that medication will be administered in about 15 minutes. Log out of the computer, then administer the pain medication.

Log out of the computer, then administer the pain medication. The best action by the nurse is to log out of the computer and administer the pain medication. Treating a client's pain takes priority over documentation in the computer. It would be inappropriate to ask a client to wait 15 minutes for pain medication while documentation is completed. The nurse would not leave a computer terminal while being logged in to protect the confidentiality of client information and prevent unauthorized use of the nurse's password. While it may be appropriate to ask another nurse to give the pain medication in emergent cases, completing documentation is not emergent and to facilitate continuity of care, the nurse would medicate the client.

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? Implement the necessary change for the problem. Meet with the parties involved to develop a strategy. Identify the person responsible for the problem. Revise the focus of the strategy.

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 diagnosed with acquired immunodeficiency disorder (AIDS) 10 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? Since only 10% of clients with AIDS develop non-Hodgkin lymphoma, rapid treatment may produce better, even curative results. Non-Hodgkin lymphoma occurring in clients with AIDS is usually fast growing and both treatments may bring about an initial positive result. The best treatment for AIDS-related non-Hodgkin lymphoma now is the same treatment as those clients without AIDS. When non-Hodgkin lymphoma is detected early in the client with AIDS, only a series of chemotherapy treatments is typically used.

Non-Hodgkin lymphoma occurring in clients with AIDS is usually fast growing and both treatments may bring about an initial positive result. Non-Hodgkin lymphomas in AIDS clients is usually an aggressive disorder and treatment typically consists of both chemotherapy and radiation therapy. Rapid treatment may produce an initial positive response; however, the duration of this positive response is a short period of time. AIDS clients who develop non-Hodgkin lymphoma do not do as well as clients without AIDS due to an altered immune system. Treatment options include chemotherapy, chemotherapy with radiation, stem cell transplantation, or newer therapies in clinical trials.

A client returns to the nursing division after a procedure under general anesthesia. The client reports being awake during the procedure and recalls certain events. What is the nurse's priority intervention? Inform the client that realistic dreams are common under anesthesia. Contact the hospital administrator. Check the client documentation for history of hallucinations. Notify the anesthesia practitioner.

Notify the anesthesia practitioner. The client may have experienced anesthetic awareness (intraoperative awareness), a rare event in which the client can recall surroundings or an event related to surgery while under general anesthesia. The anesthesia practitioner needs to be notified, and the client should be encouraged to discuss the experience and personal feelings with the practitioner. Early counseling after an episode of awareness can help lessen feelings of stress, confusion, or trauma associated with the experience. The hospital administrator does not need to be contacted.