mastery assessments
While grading a client's muscle strength, the nurse records a score of 4. What does this indicate? 1 No detection of muscular contraction 2 A barely detectable flicker or trace of contraction Correct3 Active movement against gravity and some resistance 4 Active movement against gravity only, not against resistance
According to the muscle-strength scale, a sore of 4 indicates active movement of the muscle against gravity and some resistance. A score of 0 indicates no muscular contraction. A score of 1 indicates a barely detectable flicker or trace of contraction. A score of 3 indicates active movement against gravity only, not against resistance.
What areas should the nurse keep in mind when participating in the planning of an organization's emergency preparedness plan? Select all that apply. Correct1 Needs for security 2 Activate telephone trees Correct3 Staffing for surge situations Correct4 Methods of communication Correct5 Definition of specific nursing roles
Before an event, nurses contribute to the development of emergency response plans to include security needs, staffing for surge situations, methods of communication, and defining specific nursing roles. Activation of telephone trees would occur during an actual disaster.
The registered nurse is delegating a task to a newly hired unlicensed nursing personnel (UNP) and feels that the UNP requires explanation. Why does the RN feel the need to provide explanation? 1 The UNP has an established professional relationship with the RN and required expertise. 2 The UNP has the willingness but is new to the professional relationship with the RN. 3 The UNP has limited knowledge and ability to perform the task. Correct4 The UNP is familiar with the ongoing process but the task is new.
Before delegating a task, the RN should ensure that the UNP is capable of performing the task and whether any guidance is required prior to performing the task. The RN's conclusion that explanation is needed indicates that the UNP is already familiar with the ongoing process but the task is new to the UNP. If the UNP has an established relationship with the RN and the required expertise, the RN's would state that "little guidance is needed." If the UNP has the willingness but is new to working with the RN, the RN and the LPN would need to establish mutual expectations and conditions for performance. If the UNP has limited knowledge and is unable to perform the task, the RN's statement would include "requires more guidance."
A 7-year-old is brought to the clinic by the mother, who tells the nurse that her child has been having trouble in school, has difficulty concentrating, and is falling behind in schoolwork since she and her husband separated 6 months ago. The mother reports that lately her child has not been eating dinner, and she often hears the child crying when alone. What basis for these behaviors should the nurse consider? 1 The child feels different from classmates. 2 The child will be happier living with the father. 3 The child is working through feelings of shame. Correct4 The child may be experiencing self-blame for the parents' breakup
Children usually blame themselves for their parents' marital problems, believing that they are the reason that a parent leaves. No data are presented to indicate that the child feels different from peers, that the child will be happier living with the father, or that the child is working through feelings of shame.
The healthcare provider prescribes cisplatin for a client with metastatic cancer. What will the nurse do to prevent toxic effects? 1 Ask the client's healthcare provider about prescribing leucovorin. 2 Encourage regular vigorous oral care. Correct3 Increase hydration to promote diuresis. 4 Assist the client in selecting foods appropriate for a high-protein, low-residue diet
Cisplatin is nephrotoxic and can cause kidney damage unless the client is adequately hydrated to flush the kidneys. Leucovorin, a form of folic acid, is used to combat toxic effects of methotrexate; cisplatin does not interfere with folic acid metabolism. Gentle, not vigorous, oral care is needed to cleanse the mouth without further aggravating the expected stomatitis. A low-residue diet is unnecessary. Prolonged gastrointestinal irritation is not the major concern; nausea and vomiting last about 24 hours, and although diarrhea may occur and last longer, it is not the primary concern.
The nurse manager has delegated tasks to a registered nurse (RN) and unlicensed assistive personnel (UAP) who are paired to provide care for a client with substance abuse. Which hospital care setting uses this model to deliver care to the clients? 1 Hospice care 2 Extended care 3 Long term care Correct4 Rehabilitative care
Clients with substance abuse require rehabilitative care. Rehabilitative care uses the partnership model to deliver care to the clients. In this model, the RN and UAP are paired to deliver the care. Hospice care is indicated for end-of-life care in clients. Extended care is provided for older clients. Long-term care is provided for clients with chronic diseases. Hospice care, extended care, and long-term care setting may not require the partnership model to deliver the care to the clients.
The registered nurse is teaching the student nurse about the concepts of delegation. Which response given by the student nurse indicates the need for further teaching? 1 Delegation always involves two individuals. Correct2 Delegation is the transfer of accountability while retaining responsibility. 3 Delegation is an important strategy for client safety and quality of client care. 4 Delegation has five rights that should be followed in the process of delegation.
Delegation is the transfer of the responsibility for the task, while the final accountability is always retained with the delegator. Delegation involves the delegator and the delegatee. Delegation is an important strategy for ensuring client safety and quality of client care. Delegation has five rights that are to be followed throughout the delegation process: right task, right person, right circumstance, right direction/communication, and right supervision.
Before assigning a task, the registered nurse makes sure that the delegation process is appropriate to the situation. To which delegation right does this situation refer? 1 Person 2 Supervision 3 Circumstance correct4 Communication
Ensuring that the delegation process is appropriate to the situation refers to right circumstance. Knowing whether the delegatee has the knowledge and experience to perform the specific task safely refers to the right person. Knowing whether the delegator is able to monitor and evaluate the client appropriately refers to the right supervision. Ensuring whether the delegator and delegatee understand a common work-related language refers to the right communication.
The nurse is caring for an Asian-American client with a diagnosis of depression. While interviewing this client the nurse notes that the client maintains traditional cultural beliefs and values. What is the most important information for the nurse to obtain about the client? 1 Dietary practices 2 Concept of space 3 Immigration status Correct4 Role within the family
If an Asian-American client adheres to traditional Asian practices, the nurse must recognize that the family is the central and most important social force acting on the individual. Dietary practices, concept of space, and immigration status are not as significant as family dynamics.
Which model of nursing care would include working "within the walls" as well as "beyond the walls" of the hospital? 1 Primary nursing method 2 Practice partnership model 3 Patient-focused care model Correct4 Nursing case-management model
In the nursing case-management model, the nurse needs to provide care for a client in nurse-managed centers, home health agencies, urgent care centers, schools, and rural settings. In the primary nursing method, a single nurse cares for a client while that client is in the hospital. In the practice partnership model, a registered nurse (RN) is paired with a technical assistant. In the patient-focused care model, an RN is paired with a cross-trained technician who provides patient-side care.
What does the nurse leader expect all members to be doing when a therapy group is achieving its objective? 1 Attending every session of the group 2 Commenting on each topic discussed by the group Correct3 Making an effort to include one another in discussions 4 Following through on obeying rules governing behavior
Making an effort to include one another in discussions demonstrates an increase in socialization and an awareness of the behavior of others. Attendance alone is an insufficient basis for evaluation of the effectiveness of group therapy. The quantity and extent of comments are not significant. Following through on obeying rules governing behavior may indicate a greater degree of impulse control on the part of the members, but this is not the primary goal of group therapy.
A hospital in an urban setting is located on two rivers which are spanned by several bridges. Resources arrive to this community via commercial trains or airplanes. Which credible threats should this hospital prepare for when constructing the emergency preparedness plan? Select all that apply. Correct1 Floods 2 Landslides Correct3 Bridge collapses Correct4 Boating accidents Correct5 Train derailments
Preparedness activities must address all credible threats to the safety of the community that could result in a disaster situation. For this community, the rivers could cause flooding. The bridges that span the rivers could collapse. Community members who use boats on the rivers could have accidents. And the trains that service the community could derail. There is no information to support the potential for landslides.
A registered nurse delegates a task to a licensed practical nurse (LPN). The nurse manager asks the registered nurse, "Are the equipment and resources available for the LPN to complete the task?" Which right of delegation is the nurse manager preserving? 1 Right task 2 Right direction 3 Right supervision Correct4 Right circumstance
Questions such as, "Is the environment conducive to completing the task safely?" and, "Are the equipment and resources available to complete the task?" ensure the right circumstance for delegation. Right task is ensured with a question such as, "Is the task appropriate to the delegate, according to institutional policies and procedures?" Delegation is taking the right direction if the answer to a question such as, "Do the delegator and delegatee understand a common work-related language?" is positive. Right supervision is evaluated with a question such as, "Is the delegator able to monitor and evaluate the client appropriately?"
A client is scheduled for skin cancer surgery and has not signed the consent form. Which situation will cause the nurse to legally delay signing the operative consent? 1 Ambivalent feelings are present and acknowledged. Correct2 A sedative type of medication has been given recently. 3 A complete history and physical has not been performed and recorded. 4 A discussion of alternatives with two primary healthcare providers has not occurred.
Sedation may interfere with the client's knowledge of the consent form. Many clients face contradictory feelings regarding their impending surgery, but their consent is legal unless they withdraw the consent. A complete history and physical examination are needed before surgery, but they do not affect the legality of consent. A second opinion is not required for a consent to be legal.
The charge nurse is teaching the newly-hired registered nurse (RN) about delegating tasks to unlicensed nursing personnel (UNPs). Which statement made by the newly hired RN indicates the need for further teaching? 1 "I should assist the staff in interpreting." 2 "I should assist the staff in decision-making." 3 "I should assist the staff in achieving optimal functioning." Correct4 "I should assist the staff in sorting out and articulating values."
The RN does not assist the staff in sorting out and articulating the values, the healthcare provider or the physicians do. The RN should assist the staff in interpreting to achieve better outcomes. As a delegator, it is the duty of the RN to help the staff in decision-making. The RN should assist the staff in achieving optimal functioning because the allotted task can have a better outcome only under the supervision of the RN.
A registered nurse teaches a student nurse about delegation. Which statement made by the student nurse indicates appropriate learning? 1 "Licensed practical nurses are accountable for the tasks they perform." 2 "Complete client care can be delegated to the licensed practical nurse." 3 "Professional aspects of care can be carefully delegated to the licensed practical nurse." Correct4 "Licensed practical nurses can be expected to perform tasks with which they have experience."
The delegator can safely delegate the task to the LPN if the task is within the scope of function or if the LPN is very experienced in performing the task. The LPN, being a delegatee, is not held accountable for the delegated work; the LPN is held responsible for the delegated task. The delegator is held accountable for the LPN's work. The delegator can never delegate complete client care to the LPN, but can only transfer functions and tasks. Basic skills such as activities of daily living and personal hygiene can be delegated by the delegator, but professional aspects of care should not be delegated.
A pregnant immigrant notices cultural differences in the way that pregnant women are cared for where she now lives. Which component of cultural competence is being demonstrated when the nurse motivates the immigrant to accept these differences? Correct1 Cultural desire 2 Cultural awareness 3 Cultural knowledge 4 Cultural encounters
The nurse is using cultural desire as a part of cultural competence. This component is related to motivation and commitment towards the care of an individual. Through this, an immigrant may become open to cultural differences and accept them. Cultural awareness is an in-depth self-examination of backgrounds and recognizing biases and prejudices. Cultural knowledge is a comparative study about the beliefs and care practices of other cultures. Cultural encounter is about transcultural interactions for effective communication and development.
The client diagnosed with a fistula between the bowel and urinary bladder reports passing air and bubbles during urination. What does the nurse anticipate the client's condition to be? 1 Nocturia 2 Oliguria Correct3 Pneumaturia 4 Stress incontinence
The occurrence of gas along with urination is called pneumaturia and could result from the formation of a fistula between the bowel and urinary bladder. Frequent urination during the night is called nocturia and is associated with conditions such as heart failure and diabetes mellitus. In medical conditions such as severe dehydration and shock, the urine output is reduced to 100 to 400 mL/day and this is termed oliguria. Weak sphincter control, urinary retention, and estrogen deficiency are some causes for stress incontinence or involuntary urination during increased pressure situations.
The RN caring for a postoperative hysterectomy client is delegating tasks to the licensed practical nurse (LPN). Which statement made by the RN indicates the principle of right communication of delegation? Correct1 "Does the LPN understand when to report the vital signs?" 2 "Can the LPN monitor blood pressure of the client effectively?" 3 "Can the LPN provide effective feedback regarding the client's condition?" 4 "Does the LPN have enough knowledge regarding administration of intravenous (IV) fluids to the client?"
The principle of right communication of delegation includes the qualities of the delegatee understanding when and how to report to the delegator. Monitoring and evaluating the client's condition falls under right supervision of delegation. Assessing the delegatee's ability to provide feedback in right situation indicates right supervision of delegation. Right task of delegation includes assessment of delegatee's knowledge and experience about performing the task.
The nurse is relating to and inspiring the client who has a psychiatric disorder to achieve the client outcomes. Which of Gardner's leadership tasks is reflected in the nurse's actions?
motivating
A home care nurse is visiting a family for the first time. The family's 4-week-old infant underwent surgery for exstrophy of the bladder and creation of an ileal conduit soon after birth. When the nurse arrives, the mother appears tired and the baby is crying. After an introduction, which is the most appropriate statement by the nurse?
tell me about your daily routine
Dinoprostone is a prostaglandin that stimulates uterine contractions to promote the progression of labor. Clomiphene, menotropins, and choriogonadotropin alfa are fertility drugs that are used to increase the likelihood of conception in an infertile woman.
Dinoprostone is a prostaglandin E 2 abortifacient and cervical ripening drug, which is indicated for uterine evacuation in cases of miscarriage. Clomiphene is indicated for female infertility in some clients. Magnesium sulfate is used to treat pregnancy-induced hypertension. Methylergonovine is used to treat postpartum uterine atony and hemorrhage.
The registered nurse assesses if an unlicensed assistive personnel (UAP) new to the unit is capable of carrying out a task. Which principle of delegation does this illustrate? 1 Right task Correct2 Right person 3 Right circumstance 4 Right communication
The right person is to select a person with appropriate expertise to complete the task. The right task is the right based on institutional polices. The right communication is to know whether the delegator and delegatee can understand a common work-related language. The right circumstance is to know which delegation process is appropriate to the situation.
A nurse is working with a cardiologist for a client needing temporary pacing. Which methods are examples that the cardiologist with the assistance of the nurse might use? Select all that apply. 1 Implantable cardioverter defibrillators (ICDs) Correct2 Transcutaneous pacing Correct3 Transvenous pacing 4 Biventricular pacing Correct5 Epicardial pacing
2, 3, 5 Types of temporary pacemakers include transcutaneous, where electrical stimulation is delivered through the skin via external electrode pads connected to an external pacemaker; transvenous, where a pacing catheter is inserted percutaneously into the right ventricle where it contacts the endocardium near the ventricular septum and is connected to a small external pulse generator by electrode wires; and epicardial, where pacing wires are inserted into the epicardial wall of the heart during cardiac surgery, are brought through the chest wall, and can be connected to a pulse generator if needed. Permanent pacemakers have electrode wires that are typically placed transvenously through the cephalic or subclavian vein into the heart chambers. The leads are attached to the pulse generator and placed in a surgically created pocket just below the left clavicle. ICDs and biventricular pacemakers are permanent pacemakers that have an additional electrode wire placed through the coronary sinus into the left ventricle. Additional pacing wires are in the atria and the ventricle. Pacing both ventricles simultaneously improves heart function in a certain number of heart failure clients. Synchronous depolarization of both ventricles improves cardiac output and ejection fraction.
At 7:00 AM a nurse learns that an adolescent with diabetes had a 6:30 AM fasting blood glucose level of 180 mg/dL (10.0 mmol/L). What is the priority nursing action at this time? 1 Encouraging the adolescent to start exercising 2 Asking the adolescent to obtain an immediate glucometer reading 3 Informing the adolescent that a complex carbohydrate such as cheese should be eaten Correct4 Telling the adolescent that the prescribed dose of rapid-acting insulin should be administered
A blood glucose level of 180 mg/dL (10.0 mmol/L) is above the average range, and the prescribed rapid-acting insulin is needed. Although exercise does decrease insulin requirements and does lower the blood glucose level, the immediate action of insulin is needed. Asking the adolescent to obtain an immediate glucometer reading is an action that will not correct the problem; the blood glucose level is already known. Food intake at this time will increase the level of blood glucose.
The nurse is caring for a client after hip replacement. Which actions taken by the nurse need correction? Select all that apply. 1 Placing a pillow between the client's legs Correct2 Requiring the client to sit in an armless chair Correct3 Crossing the client's legs at the ankles and knees 4 Requiring the client to use an elevated toilet seat 5 Keeping the client's hip in a neutral, straight position
A client who has undergone hip replacement needs help while standing; therefore, the nurse should not have the client sit in an armless chair because the client may experience discomfort and difficulty when standing. Crossing the client's legs at the ankles and knees after a hip replacement may cause pain and venous stasis, promoting thrombus formation. Using a pillow between the legs provides comfort and helps keep the joint abducted. Use of an elevated toilet seat allows for easy movement and prevents hip dislodgement. Keeping the client's hip in a neutral, straight position prevents pain and discomfort and hip dislocation.
The nurse is managing a client who underwent cardiac bypass surgery. Which healthcare member can be safely delegated the task of monitoring electrocardiography? 1 Nurse aide 2 Certified technician Correct3 Cross-trained technician 4 Licensed vocational nurse (LVN)
A cross-trained technician is suitable for monitoring electrocardiography in a client who underwent bypass surgery. A nurse aide is an unlicensed individual who can assist the client with basic hygiene; this aide cannot monitor electrocardiography. A certified technician is also an unlicensed member who can only record the vital signs or provide basic hygiene to the client. A licensed vocational nurse (LVN) can administer oral and intramuscular medications and record the vital signs.
The nurse is preparing a client for a myelogram to detect any subtle lesions or injuries. Which information does the nurse provide to the client before the procedure? Correct1 "You may have a severe headache after the procedure." 2 "The machine will make loud noises during the procedure." 3 "Electrodes will be applied to your skin during the procedure." 4 "There may be some blood leakage on the dressing after the procedure."
A myelogram is a sensitive test for nerve impingement that can detect subtle lesions and injuries. Spinal headache is common after a myelogram because it involves incision of the spinal roots. Diagnostic studies involving the use of magnetic resonance imaging produce loud noises. Electrodes are applied to the skin in somatosensory evoked potential studies. Leakage of blood on the dressing is observed after arthrocentesis.
The nurse manager sends the nursing team to perform a pediculosis screening at an elementary school and stays behind to catch up on administrative work. Which leadership quality does the manager fail to demonstrate in this instance? 1 Willingness to grow 2 Sharing of the reward Correct3 Leading by example 4 Having a clear vision
An effective leader actively leads members toward a mutual goal as a team, rather than simply sending them to do the job. Willingness to grow as a leader is demonstrated in activities like reading about new ideas and approaches and experimenting with new concepts to enhance their abilities. An effective leader shares the rewards of success by recognizing the positive contributions of each team member. Effective leaders with a clear vision see beyond where they are and see where they are going.
Identify abnormal assessment findings in the client's musculoskeletal system. Select all that apply. Correct1 Joint crepitation Correct2 Muscular atrophy 3 Muscle strength of 5 Correct4 Tenderness of the spine 5 Full range of motion in joints
Crepitation, a cracking and popping sound of the joint, is not a normal assessment finding. Muscular atrophy, wasting of the muscle, is also an abnormal finding. Spine tenderness on palpation of spine, joints, or muscles is not a normal finding on physical assessment of the musculoskeletal system. Muscle strength of 5 indicates active movement of the muscle against full resistance without evident fatigue, or normal muscle strength. Full range of motion in the joints is a normal finding.
A young woman who is receiving treatment for premenstrual syndrome visits the primary healthcare provider and reports a headache and dry mouth. Which drugs would be responsible for these side effects? Select all that apply. 1 Danazol 2 Ibuprofen Correct3 Sertraline Correct4 Fluoxetine Correct5 Escitalopram
Drugs used to treat premenstrual syndrome include sertraline, fluoxetine, and escitalopram. The side effects of these drugs are headaches, dry mouth, dizziness, and sleep disturbances. Danazol is used to treat endometriosis. Side effects are edema and oily skin. Ibuprofen is used to treat primary dysmenorrhea. The side effects include nausea, vomiting, and indigestion.
A healthcare provider informs a client that a T-tube will be in place after an abdominal cholecystectomy and a choledochostomy. What should the nurse include in the preoperative teaching for this client regarding the primary reason why a T-tube is necessary? 1 Drain bile from the cystic duct Correct2 Keep the common bile duct patent 3 Prevent abscess formation at the surgical site 4 Provide a port for contrast dye in a cholangiogram
Exploration of the common bile duct may cause edema; a T-tube prevents edema from obstructing the duct. The cystic duct is ligated when the gallbladder is removed. The T-tube will not prevent the formation of an abscess. A T-tube can be used to inject dye for a cholangiogram, but it is not inserted for that purpose.
A registered nurse delegated a task to the unlicensed nursing personnel (UNP) and is supervising the UNP. Which statements made by the nurse after the UNP completes the task can yield a positive outcome from the UNP? Select all that apply. Correct1 "Nice job." 2 "What is wrong with you?" Correct3 "You performed that task safely and professionally." 4 "Did the client respond positively to the nursing care?" Correct5 "The task was well done, but there is room for improvement."
Feedback, when given clearly and honestly, will yield a positive outcome from the UNP. When the nurse says, "You performed that task safely and professionally," or "The task was well done, but there is room for improvement," it shows that the UNP's work is recognized. Statements such as, "Nice job," are vague and ineffective. Statements such as, "What is wrong with you?" will be perceived as a verbal attack and will not have any positive effect. Questions should be open-ended, in order to encourage the UNP to share experiences with the RN. "Did the client respond positively to the nursing care?" is a closed-ended question that cannot be described further.
During which period of pregnancy may drug exposure cause meromelia, cleft lip, and enamel hypoplasia? 1 Fetal period Correct2 Embryonic period 3 Presomite period 4 Preimplantation period
Gross malformations may occur during the embryonic period when the basic shape of the fetus starts to develop. Teratogenic exposure during the fetal period may cause a disruption in the functional ability of the fetus. Teratogenic exposure during the presomite period or preimplantation period may result in fetal death.
The registered nurse (RN) delegates obtaining and recording a client's pulse every 30 minutes. During the last hour, the licensed practical nurse (LPN) fails to report the client's elevated heart rate to the RN. Which factor best explains the situation? 1 Limited delegation 2 Information salience Correct3 Decayed information 4 Ineffective supervision
Information decay is the characteristic feature of communication that occurs when the client's health status changes rapidly; this might include a change in the client's vital signs such as the heartbeat. Nursing when performed with limited delegation leads to misusing valuable resources. Information salience is a characteristic feature of communication in which the information provided by the delegator is monitored and evaluated. Supervision is mainly provided to the new delegatees.
The nurse is administering lactulose to a client with a history of cirrhosis of the liver. The client asks the nurse why this medication is needed because the client is not constipated. How will the nurse respond? 1 "This medication helps you to stop drinking so much alcohol." 2 "This medication helps you relax and not feel anxious." Correct3 "This medication helps you lower the high ammonia level caused by your liver disease." 4 "This medication helps you keep your abdomen from being so distended."
Lactulose is a hyperosmotic laxative and ammonia detoxicant. It decreases serum ammonia concentration by preventing reabsorption of ammonia. Lactulose has been used to lower blood ammonia content in clients with portal hypertension and hepatic encephalopathy secondary to chronic liver disease. Lactulose has no effect on the craving for alcohol or anxiety and is not prescribed to reduce abdominal distension.
While caring for a group of clients from different ethnicities, the nurse observes that a client from Ireland is stoic and not complaining about pain. Which theory should the nurse follow in this situation? 1 Roy's Theory 2 Watson's Theory Correct3 Leininger's Theory 4 Benner and Wrubel's Theory
Leininger's theory recognizes the importance of culture and is about providing culturally specific nursing care. According to this theory, the nurse should skillfully incorporate the client's cultural practices in the assessment of the client's level of pain. According to Roy's theory, the goal of nursing is to help the person adapt to changes in physiological needs, self-concept, role function, and interdependent relations during health and illness. Watson's theory defines the outcome of nursing activity with regard to the humanistic aspects. Benner and Wrubel's theory explains that personal concern is an inherent feature of nursing practice.
A client is diagnosed with Parkinson disease and receives a prescription for levodopa therapy. What does the nurse identify as the drug's mechanism of action? 1 Blocks the effects of acetylcholine Incorrect2 Increases the production of dopamine Correct3 Restores the dopamine levels in the brain 4 Promotes the production of acetylcholine
Levodopa is a precursor of dopamine, a catecholamine neurotransmitter; it increases dopamine levels in the brain that are depleted in Parkinson disease. Blocking the effects of acetylcholine is accomplished by anticholinergic drugs. Increasing the production of dopamine is ineffective because it is believed that the cells that produce dopamine have degenerated in Parkinson disease. Levodopa does not affect acetylcholine production.
After a large-scale disaster event, a client reports a feeling of numbness for 1 month. On assessment, the nurse notes a high score of all subscales of the impact of event scale—revised (IES-R) tool. Which healthcare professional should the nurse refer the client to for further evaluation? Correct1 Psychiatrist 2 Triage officer 3 Social worker 4 Mental health counselor
Reporting a feeling of numbness more than 2 weeks after a disaster event indicates risk of post-traumatic stress disorder (PTSD). The client should be assessed using the impact of event scale—revised (IES-R) tool and should be referred to a psychiatrist if the scores on all subscales are high. The triage officer evaluates each client to determine priorities for treatment. The client is referred to a social worker or mental health counselor for counseling if any one subscale score of IES-R is high.
The nurse as a leader obtains feedback from superiors, followers, and peers. Which leadership theory is the nurse putting into practice? Correct1 Style theories 2 Trait theories 3 Two-factor theory 4 Situational-contingency theories
Style theories of leadership or the group and exchange theories of leadership focus on what leaders do in relational and contextual terms. In this type of leadership, the leader obtains feedback from superiors, followers, and peers so as to pursue effective relationships with subordinates. Trait theories of leadership focus on self-awareness of traits in self-development. Two-factor theory of leadership utilizes both hygiene and motivator factors to recruit and retain staff. Situational-contingency theories of leadership imply that the nurse should assess each situation and determine appropriate action.
A client comes to a trauma center reporting that she has been raped. She is disheveled, pale, and staring blankly. The nurse asks the client to describe what happened. What is the nurse's rationale for doing this? 1 It will help the nursing staff give legal advice and provide counseling. 2 Talking about the assault will help the client see how her behavior may have led to the event. Correct3 It will let the victim put the event in better perspective and help begin the resolution process. 4 Discussing the details will keep the victim from concealing the intimate happenings during the assault.
Talking about what actually happened helps the client sort out the truth from confused thoughts and helps the client begin to accept what has happened as a part of her history. Legal counsel should come from a legal authority, not the nurse; the victim should be told of the legal services available. Sexual assaults are often planned. They are violent acts, and the perpetrators are responsible for their behavior. If the client does not want to discuss intimate details, this wish should be respected.
After assessing the conditions of four clients, the nursing manager is planning to delegate tasks to the members of the healthcare team. Which client care should be delegated to an unlicensed assistive personnel (UAP) to achieve effective outcomes in care? client A hearing loss due to accumulation of cerumen-irrigate ear client B skin injury-cleaning, medicating, and dressing client C renal calculi removal- assessing urinary output correct client D orthopedic surgery-caring and taking VS
The UAP is eligible to assist and take the client's vital signs post surgically, so an effective outcome can be expected if this task is delegated to the UAP taking care of client D. Ear irrigation in client A should be performed by the licensed practical nurse. In client B, medication should be provided along with cleaning and dressing so this task should be delegated to a licensed practical nurse. In client C, urine output should be monitored by the registered nurse.
A client with an organic mental disorder becomes increasingly agitated and abusive. The primary healthcare provider prescribes haloperidol. For what untoward effects will the nurse assess the client? 1 Jaundice and vomiting 2 Tardive dyskinesia and nausea Correct3 Parkinsonism and agranulocytosis 4 Hiccups and postural hypotension
The parkinsonian signs and symptoms are related to extrapyramidal tract effects, and agranulocytosis is related to bone marrow depression. Jaundice is an adverse reaction; vomiting is not. Tardive dyskinesia is an adverse reaction; nausea is not. The occurrence of orthostatic hypotension is low; hiccups usually do not occur.
Which strategy should be implemented by the registered nurse (RN) to achieve desirable client outcomes? 1 Doing 2 Asking 3 Talking Correct4 Offering
The registered nurse (RN) assists other nurses with delegation decisions by using three main strategies. Offering involves making a suggestion to facilitate the achievement of a desirable client outcome. Doing is the strategy that involves demonstrating the specific task or behavior to improve client care. Asking questions provides an opportunity to open lines of communication between delegator and delegate; it also helps the delegator examine the different situations and allows the nurses to reassess. Talking is the leadership style implemented by the delegator when the delegatee is unwilling to perform the task and the mutual relationship between the delegator and delegatee is only for a short duration.
A client is brought to the emergency department following ingestion of pesticides. The primary health care provider orders gastric suction. Which task can be delegated to the unlicensed assistive personnel (UAP) in this situation? 1 Monitoring the vital signs 2 Evaluating the client response 3 Gastric suctioning through vented tube Correct4 Emptying and measuring the gastric drainage
Unlicensed assistive personnel (UAP) scope of practice is limited to providing basic care, comfort, and hygiene. The UAP can measure the drainage and report the finding before emptying it. Unlicensed assistive personnel (UAP) can monitor vital signs only for clients in a stable condition. This client has an acute condition, so monitoring the vital signs is the role of registered nurse. Evaluating the client response is the role of registered nurse. UAP may perform all hygiene tasks; however, gastric suctioning through a vented tube is not within the scope of practice of the UAP. Test-Taking Tip: The UAP has limited scope when delivering care to clients with acute conditions. When answering questions related to acute care settings, be specific about the role of the UAP.
After a client with multiple fractures of the left femur is admitted to the hospital for surgery, the client demonstrates cyanosis, tachycardia, dyspnea, restlessness, and petechiae on the chest. What should the nurse do first? 1 Obtain vital signs. Correct2 Administer oxygen. 3 Call the healthcare provider. 4 Place the client in the high-Fowler position.
Vital signs should be done after oxygen administration. Obtaining vital signs will delay an intervention that may help reduce the client's distress. The client probably has a fat embolus; oxygen reduces the surface tension of fat globules, reducing hypoxia. Interventions should be initiated to help the client before taking the time to notify the healthcare provider. Placing the client in the high-Fowler position will cause hip flexion, putting stress on the fractured femur; the low or semi-Fowler positions are preferred.
While assigning a task, the registered nurse finds that one of the delegatees is not competent to hold the current position. Which strategy does the nurse follow for managing this issue during delegation? 1 Attacking the delegate verbally 2 Doing the task himself or herself 3 Adjusting the quality of client care Correct4 Lowering the expectations temporarily
When the delegatee is not competent to hold the current position, the registered nurse temporarily lowers expectations. Temporarily lowering the expectations helps the delegatee to build strengths, minimize weaknesses, and gain confidence. Verbal attacking does not help in the situation but will only undermine the relationship between the delegatee and the registered nurse. If the registered nurse does the task herself or himself, the delegatee will not improve. Delegation is a process meant to improve the quality of client care but it is not a strategy to overcome the situation.
A nurse leader is teaching the nursing staff about preparing objectives. Which statements by a member of the nursing staff indicate effective learning? Select all that apply. Correct1 "I will specify the target to be achieved." Correct2 "I will not include unrealistic and unattainable goals." Correct3 "I will provide the level of accomplishment for the end result." 4 "I will include statements such as 'in the future' in the objective." 5 "I will not indicate specific teams working toward the goals."
ie.eAn effective objective should be a S.M.A.R.T. goal, i.e., it should be specific, measurable, agreed upon, realistic, and time bound. Therefore it is important to include statements that specify the target that needs to be achieved. As the objective needs to be realistic, developing unrealistic and unattainable points should be avoided. By providing the level of accomplishment for the end result, the objective is being measured. Statements like "in the future" should be excluded from the objective, because they do not provide a specific timeframe. The teams working toward goals should be specified.
