EAQ Questions

What points should the nurse remember when caring for a client who has a history of suicide attempts? (select all that apply) A. The nurse should document the measures taken to prevent suicides. B. If the client makes a suicide attempt in the hospital, this action may lead to a lawsuit. C. The client may be detained for 21 days if a judge grants an involuntary detention. D. The primary health care facility will be responsible for failing to provide adequate supervision. E. The nurse should file paperwork with the court within 96 hours of the client's admission to the facility.

A B D Why: If a client has a history of suicide attempts, the nurse should document all suicide prevention measures within the health care facility. The documentation may be helpful if a lawsuit is filed. If the client attempts suicide in the hospital, this action may lead to a lawsuit. In the event of a lawsuit, the likely allegations against the primary healthcare provider are that he or she failed to supervise the client adequately and safeguard the facilities. If a client is admitted to a health care facility **involuntarily**, the judge may determine that the client is a danger to himself or herself or others and grant an involuntary detention for 21 days. This is not applicable for all suicide-risk clients. The nurse should file with the court within 96 hours of admission to the health care facility only if the client is admitted **involuntarily**.

When trying to promote effective learning in a client with a newly diagnosed disease, what should the nurse consider? A. Client's past experiences B. Client's personal resources C. Stress of the total situation D. Type of onset of the disease

A. Client's past experiences Past experiences have the most meaningful influence on present learning

When performing a postoperative assessment, which parameter would alert the nurse to a common side effect of epidural anesthesia? A. Lowered BP B. Increased oral temperature C. Diminished peripheral pulses D. Unequal bilateral breath sounds

A. Lowered BP Why: The most important side effect to monitor in a client who has received epidural anesthesia is hypotension due to autonomic nervous system blockade. Therefore, in the immediate postoperative recovery period, the blood pressure should be assessed frequently. Other side effects include bradycardia, nausea, and vomiting.

The nurse informs a client's family that the client is in pain and does not wish to proceed with chemotherapy. What is the role of the nurse in this situation? Manager Educator Caregiver Advocate

Advocate The nurse acts as the client's advocate by communicating the client's concern to the family. As an advocate, the nurse protects the client's human and legal rights.

A registered nurse is teaching a nursing student about evidence-based practice. Which statements should the nurse include in the teaching? (select all that apply) A. "The funding source is usually external, such as a grant." B. "Evidence-based practice is conducted by practicing nurses and other healthcare team members." C. "Institutional review board approval is not needed to implement evidence-based practice." D. "Evidence-based practice uses information drawn from research to determine safe and effective nursing care." E. "Evidence is generated to find the answers for questions that are unknown about nursing practice."

B C D Why: Evidence-based practice is conducted by practicing nurses and other members of the healthcare team. Institutional review board (IRB) approval is not needed to implement evidence-based practice. However, approval is required to conduct research. Evidence-based practice uses information from research, professional experts, and personal experience to determine safe and effective nursing care with a goal of improving the patient care and outcomes. The funding source is internal (from a healthcare agency) for evidence-based practice.

A nurse caring for a client with dementia notes that the primary healthcare provider has prescribed an experimental course of treatment. What important factor should the nurse keep in mind regarding the procurement of informed consent? A. Clients with mental illness are not allowed to give consent. B. Clients with mental illness have the right to refuse treatment. C. Family members of the client need to give consent for all procedures. D. Primary healthcare providers may perform procedures without consent.

B. Clients with mental illness have the right to refuse treatment. Why: The nurse should know that a client with a mental illness has the right to refuse treatment until a court rules that he/she is incompetent for making health related decisions for himself/herself. The nurse should also remember that even clients with mental illnesses have to give their consent for medical procedures. Family members may give consent only if they are the healthcare proxies of the client. Primary healthcare providers should not perform procedures without the consent of the client.

A client has been diagnosed as brain dead. The nurse understands that this means that the client has what? A. No spontaneous reflexes B. Shallow and slow breathing C. No cortical functioning with some reflex breathing D. Deep tendon reflexes only and no independent breathing

C. No cortical functioning with some reflex breathing Why: A client who is declared as being brain dead has no function of the cerebral cortex and a flat electroencephalogram (EEG). The client may have some spontaneous breathing and a heartbeat. The guidelines established by the American Association of Neurology include coma or unresponsiveness, absence of brainstem reflexes, and apnea. There are specific assessments to validate the findings. .

Roles of a nurse: Educator

The educator role is used to explain concepts and facts about health, describe the reason for routine care activities, demonstrate procedures such as self-care activities, reinforce learning or client behavior, and evaluate the client's progress in learning.

Roles of a nurse: Caregiver

The nurse acts as a caregiver by providing measures to restore a client's physical, emotional, spiritual, and social wellbeing. The nurse also assists them in setting and meeting goals

Roles of a nurse: Advocator

helps protect the client's human and legal rights and provide assistance in asserting these rights if the need arises

Roles of a nurse: Manager

the nurse coordinates the activities of members of the nursing staff and has personnel, policy, and budgetary responsibility for a specific nursing unit or agency.