Nursing 275 Test 2

Key management behaviors

-analyze and solve problems -run the organization on a day to day basis -establish goals and outcome measures -maintain external relationships -prepares budget develop personnel, delegate task, motivate personnel

Sins of leadership

-being insensitive to needs of others - holding grudges - exhibit lacking of self-discipline; attitude - failing to act when needed

9. Twenty-four-hour observation is a good choice for restraint in which of the following patients? a. An inmate with suicidal ideation on hospice care b. A sex offender in the psychiatric intensive care unit c. An aggressive female with antisocial personality disorder d. An inmate diagnosed with paranoid schizophrenia

A

Identify the most important factor in the initial negotiation of a contract. a. Discussion of the important issues b. Posturing and showmanship c. Resolution of key conflicts d. Lack of willingness to negotiate

A

Most state practice acts do not give delegation authority to which group of health care providers? a. dependent practitioners b. independent practitioners c. RNs with associate degrees d. when the person who is assigned a task also has a license and the tasks fall under that person's scope of practice

A

What is the primary role of the Federal Mediation and Conciliation Service? a. To bring both sides together to work out a settlement b. To prevent nurses and other health-care groups from going on strike c. To develop a solution to the conflict that is binding on both sides d. To force management into accepting the employee demands

A

What is usually considered to be an unfair labor practice? a. Being fired because a physician does not like a nurse's attitude b. Being passed over for promotion with an explanation of the rationale c. Being assigned to work five weekends in a row when the policy states that nurses will be required to work as needed d. Only being allowed 2 weeks of vacation during the first year of work.

A

4. Which guidelines should direct nursing care when deescalating an angry patient? Select all that apply. a. Intervene as quickly as possible b. Identify the trigger for the anger c. Behave calmly and respectfully d. Recognize the patient's need for increased personal space e. Demands are agreed to as long as they won't result in harm to anyone

A,B,C,D

3. Which intervention(s) should the nurse implement when helping a patient expresses anger in an inappropriate manner? Select all that apply. a. Approach the patient in a calm, reassuring manner. b. Provide suggestions regarding acceptable ways of communicating anger. c. Warn the patient that being angry is not a healthy emotional state. d. Set limits on the angry behavior that will be tolerated. e. Allow any expression of anger as long as no one is hurt.

A,B,D

1. Which individuals are most at risk for displaying aggressive behavior? Select all that apply. a. An adolescent embarrassed in front of friends. b. A young male who feels rejected by the social group. c. A young adult depressed after the death of a friend. d. A middle-aged adult who feels that concerns are going unheard. e. A patient who was discovered telling a lie.

A,B,D,E

1. A client with severe sepsis has a serum lactate level of 6.2 mmol/L. The client weighs 250 pounds. To infuse the amount of fluid this client requires in 24 hours, at what rate does the nurse set the IV pump? (Record your answer using a whole number.) ____ mL/hr

ANS: 142 mL/hr The client weighs 250 pounds = 113.63636 kg. The fluid requirement for this client is 30 mL/kg = 3409 mL. To infuse this amount over 24 hours, set the pump at 142 mL/hr (3409/24 = 142).

16. Which statement provides the best rationale for closely monitoring a severely depressed patient during antidepressant medication therapy? a. As depression lifts, physical energy becomes available to carry out suicide. b. Patients who previously had suicidal thoughts need to discuss their feelings. c. For most patients, antidepressant medication results in increased suicidal thinking. d. Suicide is an impulsive act. Antidepressant medication does not alter impulsivity.

ANS: A Antidepressant medication has the objective of relieving depression. Risk for suicide is greater as the depression lifts, primarily because the patient has more physical energy at a time when he or she may still have suicidal ideation. The other options have little to do with nursing interventions relating to antidepressant medication therapy. PTS: 1 DIF: Cognitive Level: Understand (Comprehension) REF: Page 486-487 TOP: Nursing Process: Planning MSC: Client Needs: Safe, Effective Care Environment

21. The feeling experienced by a patient that should be assessed by the nurse as most predictive of elevated suicide risk is a. hopelessness. b. sadness. c. elation. d. anger.

ANS: A Of the feelings listed, hopelessness is most closely associated with increased suicide risk. Depression, aggression, impulsivity, and shame are other feelings noted as risk factors for suicide. PTS: 1 DIF: Cognitive Level: Understand (Comprehension) REF: Page 487-490 (Table 25-3) and (Nursing Care Plan 25-1) TOP: Nursing Process: Assessment MSC: Client Needs: Psychosocial Integrity

18. A depressed patient says, Nothing matters anymore. What is the most appropriate response by the nurse? a. Are you having thoughts of suicide? b. I am not sure I understand what you are trying to say. c. Try to stay hopeful. Things have a way of working out. d. Tell me more about what interested you before you became depressed.

ANS: A The nurse must make overt what is covert; that is, the possibility of suicide must be openly addressed. The patient often feels relieved to be able to talk about suicidal ideation. PTS: 1 DIF: Cognitive Level: Apply (Application) REF: Page 486-487 | Page 488-490 (Nursing Care Plan 25-1) and (Table 25-3) TOP: Nursing Process: Implementation MSC: Client Needs: Safe, Effective Care Environment

9. A college student who attempted suicide by overdose was hospitalized. When the parents were contacted, they responded, We should have seen this coming. We did not do enough. The parents reaction reflects: a. guilt. b. denial. c. shame. d. rescue feelings.

ANS: A The parents statements indicate guilt. Guilt is evident from the parents self-chastisement. The feelings suggested in the distracters are not clearly described in the scenario. PTS: 1 DIF: Cognitive Level: Understand (Comprehension) REF: Page 493-494 TOP: Nursing Process: Assessment MSC: Client Needs: Psychosocial Integrity

11. It has been 5 days since a suicidal patient was hospitalized and prescribed an antidepressant medication. The patient is now more talkative and shows increased energy. Select the highest priority nursing intervention. a. Supervise the patient 24 hours a day. b. Begin discharge planning for the patient. c. Refer the patient to art and music therapists. d. Consider discontinuation of suicide precautions.

ANS: A The patient now has more energy and may have decided on suicide, especially given the prior suicide attempt history. The patient must be supervised 24 hours per day. The patient is still a suicide risk. PTS: 1 DIF: Cognitive Level: Apply (Application) REF: Page 486-487 TOP: Nursing Process: Assessment MSC: Client Needs: Safe, Effective Care Environment

24. After one of their identical twin daughters commits suicide, the parents express concern that the other twin may also have suicidal tendencies. Which reply should the nurse provide? a. Genetics are associated with suicide risk. Monitoring and support are important. b. Apathy underlies suicide. Instilling motivation is the key to health maintenance. c. Your child is unlikely to act out suicide when identifying with a suicide victim. d. Fraternal twins are at higher risk for suicide than identical twins.

ANS: A Twin studies suggest the presence of genetic factors in suicide; however, separating genetic predisposition to suicide from predisposition to depression or alcoholism is difficult. Primary interventions can be helpful in promoting and maintaining health and possibly counteracting genetic load. The incorrect options are untrue statements or an oversimplification. PTS: 1 DIF: Cognitive Level: Apply (Application) REF: Page 483-484 TOP: Nursing Process: Implementation MSC: Client Needs: Psychosocial Integrity

5. A client is in shock and the nurse prepares to administer insulin for a blood glucose reading of 208 mg/dL. The spouse asks why the client needs insulin as the client is not a diabetic. What response by the nurse is best? a. High glucose is common in shock and needs to be treated. b. Some of the medications we are giving are to raise blood sugar. c. The IV solution has lots of glucose, which raises blood sugar. d. The stress of this illness has made your spouse a diabetic.

ANS: A High glucose readings are common in shock, and best outcomes are the result of treating them and maintaining glucose readings in the normal range. Medications and IV solutions may raise blood glucose levels, but this is not the most accurate answer. The stress of the illness has not made the client diabetic.

9. A client is receiving norepinephrine (Levophed) for shock. What assessment finding best indicates a therapeutic effect from this drug? a. Alert and oriented, answering questions b. Client denial of chest pain or chest pressure c. IV site without redness or swelling d. Urine output of 30 mL/hr for 2 hours

ANS: A Normal cognitive function is a good indicator that the client is receiving the benefits of norepinephrine. The brain is very sensitive to changes in oxygenation and perfusion. Norepinephrine can cause chest pain as an adverse reaction, so the absence of chest pain does not indicate therapeutic effect. The IV site is normal. The urine output is normal, but only minimally so.

13. A client in shock is apprehensive and slightly confused. What action by the nurse is best? a. Offer to remain with the client for awhile. b. Prepare to administer antianxiety medication. c. Raise all four siderails on the clients bed. d. Tell the client everything possible is being done.

ANS: A The nurses presence will be best to reassure this client. Antianxiety medication is not warranted as this will lower the clients blood pressure. Using all four siderails on a hospital bed is considered a restraint in most facilities, although the nurse should ensure the clients safety. Telling a confused client that everything is being done is not the most helpful response.

11. A client has been brought to the emergency department after being shot multiple times. What action should the nurse perform first? a. Apply personal protective equipment. b. Notify local law enforcement officials. c. Obtain universal donor blood. d. Prepare the client for emergency surgery

ANS: A The nurses priority is to care for the client. Since the client has gunshot wounds and is bleeding, the nurse applies personal protective equipment (i.e., gloves) prior to care. This takes priority over calling law enforcement. Requesting blood bank products can be delegated. The nurse may or may not have to prepare the client for emergency surgery.

3. The nurse gets the hand-off report on four clients. Which client should the nurse assess first? a. Client with a blood pressure change of 128/74 to 110/88 mm Hg b. Client with oxygen saturation unchanged at 94% c. Client with a pulse change of 100 to 88 beats/min d. Client with urine output of 40 mL/hr for the last 2 hours

ANS: A This client has a falling systolic blood pressure, rising diastolic blood pressure, and narrowing pulse pressure, all of which may be indications of the progressive stage of shock. The nurse should assess this client first. The client with the unchanged oxygen saturation is stable at this point. Although the client with a change in pulse has a slower rate, it is not an indicator of shock since the pulse is still within the normal range; it may indicate the clients pain or anxiety has been relieved, or he or she is sleeping or relaxing. A urine output of 40 mL/hr is only slightly above the normal range, which is 30 mL/hr.

2. Which nursing interventions will be implemented for a patient who is actively suicidal? Select all that apply. a. Maintain arms-length, one-on-one direct observation at all times. b. Check all items brought by visitors and remove risk items. c. Use plastic eating utensils; count utensils upon collection. d. Remove the patients eyeglasses to prevent self-injury. e. Interact with the patient every 15 minutes.

ANS: A, B, C One-on-one observation is necessary for anyone who has limited or unreliable control over suicidal impulses. Finger foods allow the patient to eat without silverware; no silver or glassware orders restrict access to a potential means of self-harm. Every-15-minute checks are inadequate to assure the safety of an actively suicidal person. Placement in a public area is not a substitute for arms-length direct observation; some patients will attempt suicide even when others are nearby. Vision impairment requires eyeglasses (or contacts); although they could be used dangerously, watching the patient from arms length at all times would allow enough time to interrupt such an attempt and would prevent the disorientation and isolation that uncorrected visual impairment could create. PTS: 1 DIF: Cognitive Level: Apply (Application) REF: Page 491-492 (Table 25-5) and (Box 25-4) TOP: Nursing Process: Implementation MSC: Client Needs: Safe, Effective Care Environment

3. The nurse caring frequently for older adults in the hospital is aware of risk factors that place them at a higher risk for shock. For what factors would the nurse assess? (Select all that apply.) a. Altered mobility/immobility b. Decreased thirst response c. Diminished immune response d. Malnutrition e. Overhydration

ANS: A, B, C, D Immobility, decreased thirst response, diminished immune response, and malnutrition can place the older adult at higher risk of developing shock. Overhydration is not a common risk factor for shock.

MULTIPLE RESPONSE 1. A nurse assesses five newly hospitalized patients. Which patients have the highest suicide risk? Select all that apply. a. 82-year-old white male b. 17-year-old white female c. 22-year-old Hispanic male d. 19-year-old Native American male e. 39-year-old African American male

ANS: A, B, D Whites have suicide rates almost twice those of non-whites, and the rate is particularly high for older adult males, adolescents, and young adults. Other high-risk groups include young African American males, Native American males, and older Asian Americans. Rates are not high for Hispanic males. PTS: 1 DIF: Cognitive Level: Analyze (Analysis) REF: Page 481-485 TOP: Nursing Process: Assessment MSC: Client Needs: Psychosocial Integrity

5. The nurse is caring for a client with suspected severe sepsis. What does the nurse prepare to do within 3 hours of the client being identified as being at risk? (Select all that apply.) a. Administer antibiotics. b. Draw serum lactate levels. c. Infuse vasopressors. d. Measure central venous pressure. e. Obtain blood cultures.

ANS: A, B, E Within the first 3 hours of suspecting severe sepsis, the nurse should draw (or facilitate) serum lactate levels, obtain blood cultures (or other cultures), and administer antibiotics (after the cultures have been obtained). Infusing vasopressors and measuring central venous pressure are actions that should occur within the first 6 hours.

1. The student nurse studying shock understands that the common manifestations of this condition are directly related to which problems? (Select all that apply.) a. Anaerobic metabolism b. Hyperglycemia c. Hypotension d. Impaired renal perfusion e. Increased perfusion

ANS: A, C The common manifestations of shock, no matter the cause, are directly related to the effects of anaerobic metabolism and hypotension. Hyperglycemia, impaired renal function, and increased perfusion are not manifestations of shock.

3. A college student is extremely upset after failing two examinations. The student said, No one understands how this will hurt my chances of getting into medical school. The student then suspends access to his social networking website and turns off his cell phone. Which suicide risk factors are evident? Select all that apply. a. Shame b. Panic attack c. Humiliation d. Self-imposed isolation e. Recent stressful life event

ANS: A, C, D, E Failing examinations in the academic major constitutes a recent stressful life event. Shame and humiliation related to the failure can be hypothesized. The statement, No one can understand, can be seen as recent lack of social support. Terminating access to ones social networking site and turning off the cell phone represents self-imposed isolation. The scenario does not provide evidence of panic attack. PTS: 1 DIF: Cognitive Level: Apply (Application) REF: Page 481-483 TOP: Nursing Process: Assessment MSC: Client Needs: Psychosocial Integrity

2. The nurse caring for hospitalized clients includes which actions on their care plans to reduce the possibility of the clients developing shock? (Select all that apply.) a. Assessing and identifying clients at risk b. Monitoring the daily white blood cell count c. Performing proper hand hygiene d. Removing invasive lines as soon as possible e. Using aseptic technique during procedures

ANS: A, C, D, E Assessing and identifying clients at risk for shock is probably the most critical action the nurse can take to prevent shock from occurring. Proper hand hygiene, using aseptic technique, and removing IV lines and catheters are also important actions to prevent shock. Monitoring laboratory values does not prevent shock but can indicate a change.

4. A client is in the early stages of shock and is restless. What comfort measures does the nurse delegate to the nursing student? (Select all that apply.) a. Bringing the client warm blankets b. Giving the client hot tea to drink c. Massaging the clients painful legs d. Reorienting the client as needed e. Sitting with the client for reassurance

ANS: A, D, E The student can bring the client warm blankets, reorient the client as needed to decrease anxiety, and sit with the client for reassurance. The client should be NPO at this point, so hot tea is prohibited. Massaging the legs is not recommended as this can dislodge any clots present, which may lead to pulmonary embolism.

22. Which statement by a depressed patient will alert the nurse to the patients need for immediate, active intervention? a. I am mixed up, but I know I need help. b. I have no one to turn to for help or support. c. It is worse when you are a person of color. d. I tried to get attention before I cut myself last time.

ANS: B Hopelessness is evident. Lack of social support and social isolation increases the suicide risk. Willingness to seek help lowers risk. Being a person of color does not suggest higher risk because more whites commit suicide than do individuals of other racial groups. Attention seeking is not correlated with higher suicide risk. PTS: 1 DIF: Cognitive Level: Apply (Application) REF: Page 487-490 (Table 25-3) and (Nursing Care Plan 25-1) TOP: Nursing Process: Planning MSC: Client Needs: Safe, Effective Care Environment

23. A patient hospitalized for 2 weeks committed suicide during the night. Which initial nursing measure will be most important regarding this event? a. Ask the information technology manager to verify the hospital information system is secure. b. Hold a staff meeting to express feelings and plan care for the other patients. c. Ask the patients roommate not to discuss the event with other patients. d. Prepare a report of a sentinel event.

ANS: B Interventions should help the staff and patients come to terms with the loss and grow because of the incident. Then, a community meeting should occur to allow other patients to express their feelings and request help. Staff should be prepared to provide additional support and reassurance to patients and should seek opportunities for peer support. A sentinel event report can be prepared later. The other incorrect options will not control information or would result in unsafe care. PTS: 1 DIF: Cognitive Level: Apply (Application) REF: Page 487-488 | Page 493-494 TOP: Nursing Process: Implementation MSC: Client Needs: Safe, Effective Care Environment

4. Which change in the brains biochemical function is most associated with suicidal behavior? a. Dopamine excess b. Serotonin deficiency c. Acetylcholine excess d. Gamma-aminobutyric acid deficiency

ANS: B Research suggests that low levels of serotonin may play a role in the decision to commit suicide. The other neurotransmitter alterations have not been implicated in suicidality. PTS: 1 DIF: Cognitive Level: Understand (Comprehension) REF: Page 484-485 TOP: Nursing Process: Assessment MSC: Client Needs: Physiological Integrity

1. An adult outpatient diagnosed with major depression has a history of several suicide attempts by overdose. Given this patients history and diagnosis, which antidepressant medication would the nurse expect to be prescribed? a. Amitriptyline (Elavil), a sedating tricyclic medication b. Fluoxetine (Prozac), a selective serotonin reuptake inhibitor c. Desipramine (Norpramin), a stimulating tricyclic medication d. Tranylcypromine sulfate (Parnate), a monoamine oxidase inhibitor

ANS: B Selective serotonin reuptake inhibitor antidepressants are very safe in overdosage situations, which is not true of the other medications listed. Given this patients history of overdosing, it is important that the medication be as safe as possible in case she takes an overdose of her prescribed medication. PTS: 1 DIF: Cognitive Level: Analyze (Analysis) REF: Page 492 TOP: Nursing Process: Planning MSC: Client Needs: Physiological Integrity

6. A nurse uses the SAD PERSONS scale to interview a patient. This tool provides data relevant to: a. current stress level. b. suicide potential. c. mood disturbance. d. level of anxiety.

ANS: B The SAD PERSONS tool evaluates 10 major risk factors in suicide potential: sex, age, depression, previous attempt, ethanol use, rational thinking loss, social supports lacking, organized plan, no spouse, and sickness. The tool does not have categories to provide information on the other options listed. PTS: 1 DIF: Cognitive Level: Understand (Comprehension) REF: Page 486-487 (Table 25-2) TOP: Nursing Process: Assessment MSC: Client Needs: Psychosocial Integrity

10. Select the most critical question for the nurse to ask an adolescent who has threatened to take an overdose of pills. a. Why do you want to kill yourself? b. Do you have access to medications? c. Have you been taking drugs and alcohol? d. Did something happen with your parents?

ANS: B The nurse must assess the patients access to means to carry out the plan and, if there is access, alert the parents to remove from the home and take additional actions to assure the patients safety. The information in the other questions may be important to ask but are not the most critical. PTS: 1 DIF: Cognitive Level: Apply (Application) REF: Page 483 (Box 25-2) | Page 486-487 TOP: Nursing Process: Assessment MSC: Client Needs: Safe, Effective Care Environment

12. A nurse is caring for several clients at risk for shock. Which laboratory value requires the nurse to communicate with the health care provider? a. Creatinine: 0.9 mg/dL b. Lactate: 6 mmol/L c. Sodium: 150 mEq/L d. White blood cell count: 11,000/mm3

ANS: B A lactate level of 6 mmol/L is high and is indicative of possible shock. A creatinine level of 0.9 mg/dL is normal. A sodium level of 150 mEq/L is high, but that is not related directly to shock. A white blood cell count of 11,000/mm3 is slightly high but is not as critical as the lactate level.

8. A client arrives in the emergency department after being in a car crash with fatalities. The client has a nearly amputated leg that is bleeding profusely. What action by the nurse takes priority? a. Apply direct pressure to the bleeding. b. Ensure the client has a patent airway. c. Obtain consent for emergency surgery. d. Start two large-bore IV catheters.

ANS: B Airway is the priority, followed by breathing and circulation (IVs and direct pressure). Obtaining consent is done by the physician.

14. A client is being discharged home after a large myocardial infarction and subsequent coronary artery bypass grafting surgery. The clients sternal wound has not yet healed. What statement by the client most indicates a higher risk of developing sepsis after discharge? a. All my friends and neighbors are planning a party for me. b. I hope I can get my water turned back on when I get home. c. I am going to have my daughter scoop the cat litter box. d. My grandkids are so excited to have me coming home!

ANS: B All these statements indicate a potential for leading to infection once the client gets back home. A large party might include individuals who are themselves ill and contagious. Having litter boxes in the home can expose the client to microbes that can lead to infection. Small children often have upper respiratory infections and poor hand hygiene that spread germs. However, the most worrisome statement is the lack of running water for handwashing and general hygiene and cleaning purposes.

1. A student is caring for a client who suffered massive blood loss after trauma. How does the student correlate the blood loss with the clients mean arterial pressure (MAP)? a. It causes vasoconstriction and increased MAP. b. Lower blood volume lowers MAP. c. There is no direct correlation to MAP. d. It raises cardiac output and MAP.

ANS: B Lower blood volume will decrease MAP. The other answers are not accurate.

7. A nurse works at a community center for older adults. What self-management measure can the nurse teach the clients to prevent shock? a. Do not get dehydrated in warm weather. b. Drink fluids on a regular schedule. c. Seek attention for any lacerations. d. Take medications as prescribed

ANS: B Preventing dehydration in older adults is important because the age-related decrease in the thirst mechanism makes them prone to dehydration. Having older adults drink fluids on a regular schedule will help keep them hydrated without the influence of thirst (or lack of thirst). Telling clients not to get dehydrated is important, but not the best answer because it doesnt give them the tools to prevent it from occurring. Older adults should seek attention for lacerations, but this is not as important an issue as staying hydrated. Taking medications as prescribed may or may not be related to hydration.

2. A nurse is caring for a client after surgery. The clients respiratory rate has increased from 12 to 18 breaths/min and the pulse rate increased from 86 to 98 beats/min since they were last assessed 4 hours ago. What action by the nurse is best? a. Ask if the client needs pain medication. b. Assess the clients tissue perfusion further. c. Document the findings in the clients chart. d. Increase the rate of the clients IV infusion.

ANS: B Signs of the earliest stage of shock are subtle and may manifest in slight increases in heart rate, respiratory rate, or blood pressure. Even though these readings are not out of the normal range, the nurse should conduct a thorough assessment of the client, focusing on indicators of perfusion. The client may need pain medication, but this is not the priority at this time. Documentation should be done thoroughly but is not the priority either. The nurse should not increase the rate of the IV infusion without an order.

4. A nurse is caring for a client after surgery who is restless and apprehensive. The unlicensed assistive personnel (UAP) reports the vital signs and the nurse sees they are only slightly different from previous readings. What action does the nurse delegate next to the UAP? a. Assess the client for pain or discomfort. b. Measure urine output from the catheter. c. Reposition the client to the unaffected side. d. Stay with the client and reassure him or her.

ANS: B Urine output changes are a sensitive early indicator of shock. The nurse should delegate emptying the urinary catheter and measuring output to the UAP as a baseline for hourly urine output measurements. The UAP cannot assess for pain. Repositioning may or may not be effective for decreasing restlessness, but does not take priority over physical assessments. Reassurance is a therapeutic nursing action, but the nurse needs to do more in this situation.

5. A college student who failed two tests cried for hours and then tried to telephone a parent but got no answer. The student then gave several expensive sweaters to a roommate and asked to be left alone for a few hours. Which behavior provides the strongest clue of an impending suicide attempt? a. Calling parents b. Excessive crying c. Giving away sweaters d. Staying alone in dorm room

ANS: C Giving away prized possessions may signal that the individual thinks he or she will have no further need for the item, such as when a suicide plan has been formulated. Calling parents, remaining in a dorm, and crying do not provide direct clues to suicide. PTS: 1 DIF: Cognitive Level: Apply (Application) REF: Page 486-487 TOP: Nursing Process: Assessment MSC: Client Needs: Psychosocial Integrity

20. When assessing a patients plan for suicide, what aspect has priority? a. Patients financial and educational status b. Patients insight into suicidal motivation c. Availability of means and lethality of method d. Quality and availability of patients social support

ANS: C If a person has plans that include choosing a method of suicide readily available and if the method is one that is lethal (i.e., will cause the person to die with little probability for intervention), the suicide risk is high. These areas provide a better indication of risk than the areas mentioned in the other options. See relationship to audience response question. PTS: 1 DIF: Cognitive Level: Apply (Application) REF: Page 486-487 TOP: Nursing Process: Assessment MSC: Client Needs: Safe, Effective Care Environment

15. Which intervention will the nurse recommend for the distressed family and friends of someone who has committed suicide? a. Participating in reminiscence therapy b. Psychological postmortem assessment c. Attending a self-help group for survivors d. Contracting for at least two sessions of group therapy

ANS: C Survivors need outlets for their feelings about the loss and the deceased person. Self-help groups provide peer support while survivors work through feelings of loss, anger, and guilt. Psychological postmortem assessment would not provide the support necessary to work through feelings of loss associated with the suicide. Reminiscence therapy is not geared to loss resolution. Contracting for two sessions of group therapy would not provide sufficient time to work through the issues associated with a death by suicide. PTS: 1 DIF: Cognitive Level: Apply (Application) REF: Page 493-494 TOP: Nursing Process: Implementation MSC: Client Needs: Psychosocial Integrity

12. A nurse and patient construct a no-suicide contract. Select the preferable wording. a. I will not try to harm myself during the next 24 hours. b. I will not make a suicide attempt while I am hospitalized. c. For the next 24 hours, I will not in any way attempt to harm or kill myself. d. I will not kill myself until I call my primary nurse or a member of the staff.

ANS: C The correct answer leaves no loopholes. The wording about not harming oneself and not making an attempt leaves loopholes or can be ignored by the patient who thinks I am not going to harm myself, I am going to kill myself or I am not going to attempt suicide, I am going to commit suicide. A patient may call a therapist and leave the telephone to carry out the suicidal plan. PTS: 1 DIF: Cognitive Level: Apply (Application) REF: Page 491-492 (Table 26-5) TOP: Nursing Process: Implementation MSC: Client Needs: Safe, Effective Care Environment

14. A nurse interacts with an outpatient who has a history of multiple suicide attempts. Select the most helpful response for a nurse to make when the patient states, I am considering committing suicide. a. Im glad you shared this. Please do not worry. We will handle it together. b. I think you should admit yourself to the hospital to keep you safe. c. Bringing up these feelings is a very positive action on your part. d. We need to talk about the good things you have to live for.

ANS: C The correct response gives the patient reinforcement, recognition, and validation for making a positive response rather than acting out the suicidal impulse. It gives neither advice nor false reassurance, and it does not imply stereotypes such as You have a lot to live for. It uses the patients ambivalence and sets the stage for more realistic problem solving. PTS: 1 DIF: Cognitive Level: Apply (Application) REF: Page 484 | Page 488-491 (Nursing Care Plan 25-1) TOP: Nursing Process: Implementation MSC: Client Needs: Psychosocial Integrity

7. A person intentionally overdosed on antidepressants. Which nursing diagnosis has the highest priority? a. Powerlessness b. Social isolation c. Risk for suicide d. Compromised family coping

ANS: C This diagnosis is the only one with life-or-death ramifications and is therefore of higher priority than the other options. PTS: 1 DIF: Cognitive Level: Apply (Application) REF: Page 487-490 (Table 25-3) TOP: Nursing Process: Diagnosis/Analysis MSC: Client Needs: Psychosocial Integrity

13. A tearful, anxious patient at the outpatient clinic reports, I should be dead. The initial task of the nurse conducting the assessment interview is to: a. assess lethality of suicide plan. b. encourage expression of anger. c. establish rapport with the patient. d. determine risk factors for suicide.

ANS: C This scenario presents a potential crisis. Establishing rapport facilitates a therapeutic alliance that will allow the nurse to obtain relevant assessment data such as the presence of a suicide plan, lethality of plan, and presence of risk factors for suicide. PTS: 1 DIF: Cognitive Level: Analyze (Analysis) REF: Page 488-491 (Nursing Care Plan 25-1) TOP: Nursing Process: Implementation MSC: Client Needs: Psychosocial Integrity

17. A nurse assesses a patient who reports a 3-week history of depression and periods of uncontrolled crying. The patient says, My business is bankrupt, and I was served with divorce papers. Which subsequent statement by the patient alerts the nurse to a concealed suicidal message? a. I wish I were dead. b. Life is not worth living. c. I have a plan that will fix everything. d. My family will be better off without me.

ANS: C Verbal clues to suicide may be overt or covert. The incorrect options are overt references to suicide. The correct option is more veiled. It alludes to the patients suicide as being a way to fix everything but does not say it outright. PTS: 1 DIF: Cognitive Level: Apply (Application) REF: Page 485-486 | Page 490 (Table 25-3) TOP: Nursing Process: Assessment MSC: Client Needs: Psychosocial Integrity

15. A client in shock has been started on dopamine. What assessment finding requires the nurse to communicate with the provider immediately? a. Blood pressure of 98/68 mm Hg b. Pedal pulses 1+/4+ bilaterally c. Report of chest heaviness d. Urine output of 32 mL/hr

ANS: C Chest heaviness or pain indicates myocardial ischemia, a possible adverse effect of dopamine. While taking dopamine, the oxygen requirements of the heart are increased due to increased myocardial workload, and may cause ischemia. Without knowing the clients previous blood pressure or pedal pulses, there is not enough information to determine if these are an improvement or not. A urine output of 32 mL/hr is acceptable.

10. A student nurse is caring for a client who will be receiving sodium nitroprusside (Nipride) via IV infusion. What action by the student causes the registered nurse to intervene? a. Assessing the IV site before giving the drug b. Obtaining a programmable (smart) IV pump c. Removing the IV bag from the brown plastic cover d. Taking and recording a baseline set of vital signs

ANS: C Nitroprusside degrades in the presence of light, so it must be protected by leaving it in the original brown plastic bag when infusing. The other actions are correct, although a smart pump is not necessarily required if the facility does not have them available. The drug must be administered via an IV pump, although the programmable pump is preferred for safety.

6. A nurse caring for a client notes the following assessments: white blood cell count 3800/mm3, blood glucose level 198 mg/dL, and temperature 96.2 F (35.6 C). What action by the nurse takes priority? a. Document the findings in the clients chart. b. Give the client warmed blankets for comfort. c. Notify the health care provider immediately. d. Prepare to administer insulin per sliding scale.

ANS: C This client has several indicators of sepsis with systemic inflammatory response. The nurse should notify the health care provider immediately. Documentation needs to be thorough but does not take priority. The client may appreciate warm blankets, but comfort measures do not take priority. The client may or may not need insulin.

25. Which individual in the emergency department should be considered at highest risk for completing suicide? a. An adolescent Asian American girl with superior athletic and academic skills who has asthma b. A 38-year-old single, African American female church member with fibrocystic breast disease c. A 60-year-old married Hispanic man with twelve grandchildren who has type 2 diabetes d. A 79-year-old single, white male diagnosed recently with terminal cancer of the prostate

ANS: D High-risk factors include being an older adult, single, male, and having a co-occurring medical illness. Cancer is one of the somatic conditions associated with increased suicide risk. Protective factors for African American women and Hispanic individuals include strong religious and family ties. Asian Americans have a suicide rate that increases with age. PTS: 1 DIF: Cognitive Level: Analyze (Analysis) REF: Page 482-483 (Box 25-2) TOP: Nursing Process: Assessment MSC: Client Needs: Psychosocial Integrity

8. A person who attempted suicide by overdose was treated in the emergency department and then hospitalized. The initial outcome is that the patient will: a. verbalize a will to live by the end of the second hospital day. b. describe two new coping mechanisms by the end of the third hospital day. c. accurately delineate personal strengths by the end of first week of hospitalization. d. exercise suicide self-restraint by refraining from attempts to harm self for 24 hours.

ANS: D Suicide self-restraint relates most directly to the priority problem of risk for self-directed violence. The other outcomes are related to hope, coping, and self-esteem. PTS: 1 DIF: Cognitive Level: Apply (Application) REF: Page 487 | Page 492 (Table 25-4) TOP: Nursing Process: Outcomes Identification MSC: Client Needs: Psychosocial Integrity

19. A nurse counsels a patient with recent suicidal ideation. Which is the nurses most therapeutic comment? a. Lets make a list of all your problems and think of solutions for each one. b. Im happy youre taking control of your problems and trying to find solutions. c. When you have bad feelings, try to focus on positive experiences from your life. d. Lets consider which problems are very important and which are less important.

ANS: D The nurse helps the patient develop effective coping skills. Assist the patient to reduce the overwhelming effects of problems by prioritizing them. The incorrect options continue to present overwhelming approaches to problem solving. PTS: 1 DIF: Cognitive Level: Apply (Application) REF: Page 484 | Page 488-489 (Nursing Care Plan 25-1) | Page 491-492 TOP: Nursing Process: Implementation MSC: Client Needs: Psychosocial Integrity

2. Four individuals have given information about their suicide plans. Which plan evidences the highest suicide risk? a. Turning on the oven and letting gas escape into the apartment during the night b. Cutting the wrists in the bathroom while the spouse reads in the next room c. Overdosing on aspirin with codeine while the spouse is out with friends d. Jumping from a railroad bridge located in a deserted area late at night

ANS: D This is a highly lethal method with little opportunity for rescue. The other options are lower lethality methods with higher rescue potential. See relationship to audience response question. PTS: 1 DIF: Cognitive Level: Analyze (Analysis) REF: Page 486-487 TOP: Nursing Process: Assessment MSC: Client Needs: Psychosocial Integrity

3. Which measure would be considered a form of primary prevention for suicide? a. Psychiatric hospitalization of a suicidal patient b. Referral of a formerly suicidal patient to a support group c. Suicide precautions for 24 hours for newly admitted patients d. Helping school children learn to manage stress and be resilient

ANS: D This measure promotes effective coping and reduces the likelihood that such children will become suicidal later in life. Admissions and suicide precautions are secondary prevention measures. Support group referral is a tertiary prevention measure. PTS: 1 DIF: Cognitive Level: Understand (Comprehension) REF: Page 487-488 TOP: Nursing Process: Implementation MSC: Client Needs: Safe, Effective Care Environment

The nurse evaluates the effectiveness of dopamine therapy for a client in shock. Which of the following may indicate treatment is successful? (Select all that apply.) 1. Improved urine output 2. Increased blood pressure 3. Breath sounds are diminished 4. Slight hypotension occurs 5. Peripheral pulses are intact

Answer: 1, 2 1. Improved urine output 2. Increased blood pressure Rationale: With increased cardiac output, renal function should improve, and there should be an increase in urine output. Blood pressure should increase with the increase in cardiac output and the drug is titrated to normal or near normal parameters. Options 3, 4, and 5 are incorrect. Dopamine does not have direct effects on breath sounds. Blood pressure should rise with improving hemodynamics, and although peripheral may be felt, the absence of peripheral pulses may be due to other conditions such as arterial or venous insufficiency and do not indicate a therapeutic response to dopamine. Cognitive Level: Analyzing Client Need: Physiological Integrity Nursing Process: Evaluation

The client in hypovolemic shock is prescribed an infusion of lactated Ringer's. What is the purpose for infusing this solution in shock? (Select all that apply.) 1. The solution will help to replace fluid and promote urine output. 2. The solution will draw water into cells. 3. The solution will draw water from cells to blood vessels. 4. The solution will help maintain vascular volume. 5. The solution is used to provide adequate calories for metabolic needs.

Answer: 1, 4 1. The solution will help to replace fluid and promote urine output. 4. The solution will help maintain vascular volume. Rationale: Crystalloid solutions such as lactated Ringer's closely approximate the electrolytes and concentration of blood plasma. They help increase vascular volume, replacing fluid and promoting adequate urine output, and help maintain normal intravascular volume. Options 2, 3, and 5 are incorrect. Lactated Ringer's is an isotonic fluid and should not cause fluid shifting into or out of the cells. It does not contain enough calories to meet the body's metabolic needs, especially in shock, which is an extremely stressful condition in the body. Cognitive Level: Analyzing Client Need: Physiological Integrity Nursing Process: Implementation

Nursing assessment of a client receiving normal serum albumin for treatment of shock include which of the following assessments? 1. Breath sounds 2. Serum glucose levels 3. Potassium level 4. Hemoglobin and hematocrit

Answer: 1. Breath sounds Rationale: Albumin is a colloid solution. Colloids pull fluid into the vascular space. Circulatory overload may occur due to this fluid shift. The nurse should assess the client for symptoms of heart failure such as an increase in adventitious breath sounds, edema, bounding pulses, or tachycardia. Options 2, 3, and 4 are incorrect. Albumin is given to increase vascular volume and should not directly affect glucose or potassium levels or hemoglobin or hematocrit concentration. Cognitive Level: Analyzing Client Need: Physiological Integrity Nursing Process: Assessment

A client who is experiencing shock is started on norepinephrine (Levophed) by IV drip. Why must the nurse conduct frequent inspections of the IV insertion site while the client remains on this drug? 1. The client's blood pressure may rise if the site is occluded. 2. Extravasation and leakage at the IV site may cause local tissue damage. 3. Bleeding may occur from the site due to localized drug effects. 4. The client's blood pressure may drop precipitously if the IV runs too quickly.

Answer: 2. Extravasation and leakage at the IV site may cause local tissue damage. Rationale: Norepinephrine (Levophed) is a potent vasoconstrictor. Extravasation or leakage at the insertion site will cause intense vasoconstriction in the local area with loss of tissue perfusion and tissue damage. Options 1, 3, and 4 are incorrect. Norepinephrine raises the blood pressure by vasoconstriction and an occluded IV would not allow the drug to be infused and the blood pressure would drop. Infusing the drug too rapidly would cause a dramatic increase in vasoconstriction and blood pressure. The drug constricts blood vessels and bleeding would not be a localized drug effect. Cognitive Level: Analyzing Client Need: Physiological Integrity Nursing Process: Evaluation

While planning care for a client receiving plasma protein fraction (Plasmanate), the nurse will include frequent assessments for which of the following possible adverse reactions? 1. Electrolyte imbalance 2. Hyperglycemia 3. Anaphylactic reaction 4. Hypotension

Answer: 3. Anaphylactic reaction Rationale: Anaphylactic reactions may occur with the use of plasma protein fraction (Plasmanate). Symptoms may include periorbital edema, urticaria, wheezing, and respiratory difficulties. Options 1, 2, and 4 are incorrect. Plasma protein fraction should not cause electrolyte imbalances or hyperglycemia. It is given as a volume expander to increase or hyperglycemia. It is given as a volume expander to increase vascular fluid volume in shock and should not cause hypotension. Cognitive Level: Analyzing Client Need: Physiological Integrity Nursing Process: Planning

A client is receiving PlasmaLyte for treatment of hypovolemic shock. When monitoring for therapeutic effects, which of the following will the nurse expect to occur? 1. Breath sounds are clear. 2. Potassium, glucose, and sodium levels remain within normal range. 3. Blood pressure returns to within normal range and urine output increases. 4. The pulse rate and ECG return to normal rate and pattern.

Answer: 3. Blood pressure returns to within normal range and urine output increases. Rationale: As fluid volume increases, blood pressure, cardiac output, and renal perfusion all increase. Blood pressure should return to normal or near normal levels and urine output should increase as renal perfusion increases. Options 1, 2, and 4 are incorrect. When given for hypovolemic shock, PlasmaLyte should increase intravascular volume. Breath sounds; potassium, glucose, and sodium levels; and pulse rate or ECG are not indicators of therapeutic effect. Cognitive Level: Applying Client Need: Physiological Integrity Nursing Process: Evaluation

The nurse evaluates the effectiveness of client education as it relates to anaphylaxis therapy. Which of the following might indicate that teaching was successful? (Select all that apply.) a. "I will seek emergency medical attention immediately if a single auto-injection of epinephrine fails to bring relief." b. "I will report burning, irritation, tenderness, or swelling at my IV injection sites to my nurse." c. "I will carry an EpiPen to administer when I experience a hypersensitivity episode to peanuts." d. "If my EpiPen does not work effectively, I can increase the dose until the symptoms disappear."

Answer: a. "I will seek emergency medical attention immediately if a single auto-injection of epinephrine fails to bring relief."; c. "I will carry an EpiPen to administer when I experience a hypersensitivity episode to peanuts." Objective: Use the steps of the nursing process to care for clients receiving drug therapy for anaphylaxis. Rationale: Anaphylaxis therapy should include goals of therapy and teaching clients regarding epinephrine. Cognitive Level: Evaluation Client Need: Health Promotion and Maintenance Nursing Process: Application

Nursing assessment of a client receiving serum albumin for treatment of shock should include: a. Assessing lung sounds. b. Monitoring glucose. c. Monitoring the potassium level. d. Monitoring hemoglobin and hematocrit.

Answer: a. Assessing lung sounds. Objective: Compare and contrast the use of colloids and crystalloids in fluid replacement therapy. Rationale: Colloids pull fluid into vascular space. Circulatory overload could occur. The nurse should assess the client for symptoms of heart failure. Cognitive Level: Assessment Client Need: Physiological Integrity Nursing Process: Application

The client in shock is prescribed an infusion of lactated Ringer's solution. The nurse recognizes that the function of this fluid in the treatment of shock is to: a. Replace fluid, and promote urine output. b. Draw water into cells. c. Draw water from cells to blood vessels. d. Maintain vascular volume.

Answer: a. Replace fluid, and promote urine output. Objective: Explain the initial treatment for a patient in shock. Rationale: Lactated Ringer's is a crystalloid solution that contains electrolytes and has a concentration similar that of plasma. It leaves the blood and enters the cells, replacing fluids and promoting urinary output. Cognitive Level: Implementation Client Need: Physiological Integrity Nursing Process: Comprehension

Which of the following requires intervention by the nurse caring for a client receiving Phenylephrine (Neosynephrine)? a. Decreased heart rate b. Decreased urinary output c. Respiratory rate 24 d. Negative Homans' sign

Answer: b. Decreased urinary output Objective: Use the steps of the nursing process to care for patients receiving drug therapy for shock. Rationale: Phenylephrine (Neosynephrine) causes vasoconstriction. Urinary output should be monitored, because extreme vasoconstriction could lead to reduced renal perfusion. Cognitive Level: Assessment Client Need: Physiological Integrity Nursing Process: Comprehension

Dobutamine (Dobutrex) is used to treat a client experiencing cardiogenic shock. Nursing intervention includes: a. Monitoring for fluid overload. b. Monitoring for cardiac dysrhythmias. c. Monitoring respiratory status. d. Monitoring for hypotension.

Answer: b. Monitoring for cardiac dysrhythmias. Objective: Use the steps of the nursing process to care for clients receiving drug therapy for shock. Rationale: Dobutamine is beneficial in cases where shock is caused by heart failure. The drug increases contractility and has the potential to cause dysrhythmias. Cognitive Level: Implementation Client Need: Physiological Integrity Nursing Process: Application

The client experiences shock following a spinal cord injury. This type of shock is classified as: a. Hypovolemic. b. Neurogenic. c. Cardiogenic. d. Anaphylactic

Answer: b. Neurogenic. Objective: Relate the general symptoms of shock to their physiologic causes. Rationale: Careful assessment indicates the type of shock. Trauma or bleeding suggests hypovolemic shock; trauma to brain or spinal cord is evidence of neurogenic shock, a type of distributive shock caused by a sudden loss of nerve impulse communications. Cognitive Level: Assessment Client Need: Physiological Integrity Nursing Process: Knowledge

The nurse should closely monitor the client receiving Dextran 70 (Macrodex) for: a. Dehydration. b. Cardiac dysrhythmias. c. Bleeding. d. Hypertension.

Answer: c. Bleeding. Objective: Compare and contrast the use of colloids and crystalloids in fluid replacement therapy. Rationale: Dextran can interfere with coagulation and platelet adhesion. The nurse should assess for unusual bleeding. Cognitive Level: Assessment Client Need: Physiological Integrity Nursing Process: Comprehension

The nurse weighs the client receiving dobutamine (Dobutrex) therapy daily. The rationale for this is to: a. Evaluate nutritional status. b. Evaluate fluid output. c. Determine drug dosage. d. Determine renal status.

Answer: c. Determine drug dosage. Objective: Use the steps in the nursing process to care for patients receiving drug therapy for shock. Rationale: Dosage is based on weight, and is recalculated each day. The client should be weighed each morning. Cognitive Level: Implementation Client Need: Physiological Integrity Nursing Process: Application

Teaching for a client receiving plasma protein fraction (Plasmanate) should include reporting which of the following possible adverse reactions? a. Unusual bleeding b. Hyperglycemia c. Difficulty breathing d. Hypotension

Answer: c. Difficulty breathing Objective: Compare and contrast the use of colloids and crystalloids in fluid replacement therapy. Rationale: Anaphylactic reaction can occur. Symptoms include periorbital edema, urticaria, wheezing, and dyspnea. Cognitive Level: Planning Client Need: Physiological Integrity Nursing Process: Application

The client care plan of a client receiving dopamine should include having phentolamine (Regitine) available for use. The purpose of this drug is to: a. Reverse hypertension. b. Treat nausea. c. Stimulate urinary output. d. Prevent necrosis if the IV extravasates.

Answer: d. Prevent necrosis if the IV extravasates. Objective: For each class of drugs, explain their mechanisms of action, primary actions, and important adverse side effects. Rationale: Extravasation of dopamine can cause severe, localized vasoconstriction that results in sloughing of tissue and necrosis, if not reversed by injection of phentolamine into the site. Cognitive Level: Planning Client Need: Physiological Integrity Nursing Process: Knowledge

3. Fill in the blanks: When they accept a delegated _____, assistive personnel accept the _______________ attached to it.

Answers: task, responsibility

2. A newly admitted male patient has a long history of aggressive behavior toward staff. Which statement by the nurse demonstrates the need for more information about the use of restraint? a. "If his behavior warrants restraints, someone will stay with him the entire time he's restrained." b. "I'll call the primary provider and get an as needed (prn) seclusion/restraint order." c. "If he is restrained, be sure he is offered food and fluids regularly." d. "Remember that physical restraints are our last resort."

B

7. A nurse named Darryl has been hired to work in a psychiatric intensive care unit. He has undergone training on recognizing escalating anger. Which statement indicates that he understands danger signs in regard to aggression? a. "I need to be aware of patients who are withdrawn and sitting alone." b. "An obvious change in behavior is a risk factor for aggression." c. "Patients who seek constant attention are more likely to be violent." d. "Patients who talk to themselves are the most dangerous."

B

In which situation is the RN responsible only for supervising ancillary personnel to make sure the tasks are carried out safely? a. When they are LPNs b. When an official body has a predesignated a list of tasks that non-nursing personnel may undertake in the care of clients. c. RNs are always responsible for the full supervision of tasks conducted by ancillary personnel. d. Legally, the authority or power to delegate is restricted to professionals who are licensed and governed by a statutory practice act.

B

Select a practice that is an indication of failure to bargain in good faith. a. Agreeing to meet at reasonable times b. Sending individuals to negotiate who cannot make binding decisions c. Unwillingness to negotiate on all issues d. Exchanging lists of demands by both sides

B

What is the most important feature of the shared governance model? a. Nursing administration retains most of the power over nurses to better regulate practice. b. Power and authority are transferred to the nursing staff rather than being located primarily in nursing administration. c. Clients are billed for nursing care as a separate item similar to the way they are billed for physician services. d. The nursing staff hierarchy structure is similar to the medical staff structure.

B

Development of Conflict Resolution Skills

Build on existing skills. Avoid personal attacks. Listen actively. Ignore trivia. Set the stage. Establish trust.

6. John Patrick is a widower with four daughters. He has enjoyed a healthy relationship with all of them until they reached puberty. As each girl began to mature physically, he acted in an aggressive manner, beating her without provocation. John Patrick is most likely acting on: a. Self-protective measures b. Stress of raising four daughters c. Frustration of unhealthy desire d. Motivating his daughters to be chaste

C

8. An effective method of preventing escalation in an environment with violent offenders is to develop a level of trust through: a. A casual authoritative demeanor b. Keeping patients busy c. Brief, frequent, nonthreatening encounters d. Threats of seclusion or punishment

C

A nurse is sitting by the bedside close to a patient to better hear him and letting him know that she has his full attention. What factor does the nurse need to keep in mind that may interfere with effective communication with this patient? a. The patient may not be hard of hearing b. The volume on the TV may be at a high setting c. The patient may have person space issues d. The nurse may need to sit closer to be most effective

C

What communication technique will make patients less likely to perceive communication from the nurse, as a personal attack? a. Using a firm, confident tone of voice b. Using encouraging words such as "Okay," and "Tell me more." c. Using "I" rather than "you" statements d. Keeping the conversation light

C

What is a list of tasks that certain health-care personnel can perform that is produced by the health-care facility known as? a. policy and procedures b. special delegation tasks c. indirect delegation d. consensus delegation

C

What is the primary reason that a nurse use silence when communicating with a patient about his diagnosis? a. A period of silence makes the patient feel uncomfortable b. Several periods of silence makes the teaching session longer c. Silence periods allow the patient to gather their thoughts before speaking d. Silence periods allow the nurse to think of her next question for the patient

C

Which of the following is an accurate statement about the person who is authorized to receive a delegated task? a. They do not have to be qualified to perform the task by the state practice act. b. The authorization does not hold any legal status. c. The task must fall under the RN's scope of practice. d. The task must fall under the physician's scope of practice.

C

Factors That Affect Communication

Change Fear of the unknown Anger Positive or negative expression Group dynamics Unwritten rules Competition Peer evaluation Working environment Coping with difficult behavior Stress A destructive circle

Functions of nurse manager

Conduct orientation of new staff. Evaluate staff. Terminate employees with unsatisfactory work performance. Develop time schedules that cover the unit safely. Make team and staff assignments. Develop a realistic budget for the unit. Justify the number of nursing hours used by the unit. Call in nurses on their days off when staffing falls short. Attend nursing management meetings. Hold regular meetings with unit staff to resolve problems; implement new policies and procedures. Set unit goals for staff. Contribute to facility goals. Communicate regularly with physicians about unit problems. Conduct quality assurance studies. Provide rewards for high-quality care. Implement programs. Analyze and solve problems. Day-to-day running of the organization. Manage finances. Maintain external relationships. Develop personnel. Delegate tasks. Organize activities. Motivate staff.

Conflict Resolution

Conflict on the job A common situation that causes conflict is when nurses feel overworked or overwhelmed by their assignments. "Why isn't anyone helping me?"

The nurse is concerned that a client who had myocardial infarction (MI) has developed cardiogenic shock. Which findings indicate shock? (Select all that apply.) Bradycardia Cool, diaphoretic skin Crackles in the lung fields Respiratory rate of 12 breaths/min Anxiety and restlessness Temperature of 100.4° F

Cool, diaphoretic skin Crackles in the lung fields Anxiety and restlessness The client with shock has cool, moist skin. Because of extensive tissue necrosis, the left ventricle cannot forward blood adequately, resulting in pulmonary congestion and crackles. Because of poor tissue perfusion, a change in mental status, anxiety, and restlessness are expected. All types of shock (except neurogenic) present with tachycardia, not bradycardia. Due to pulmonary congestion, a client with cardiogenic shock typically has tachypnea. Cardiogenic shock does not present with low-grade fever; this would be more likely to occur in pericarditis.

10. Chronic obstructive pulmonary disease, spinal injury, seizure disorder, and pregnancy are conditions that: a. Frequently result in out of control behavior. b. Respond well to therapeutic holding. c. Necessitate the use of only two-point restraint. d. Contraindicate restraint and seclusion.

D

5. Which comorbid condition would result in cautious use of a selective serotonin reuptake inhibitors for a patient with chronic aggression? a. Asthma b. Anxiety disorder c. Glaucoma d. Bipolar disorder

D

When a nurse delegates tasks, the outcomes of tasks should be: a. Related to the patient's nursing diagnosis. b. In line with hospital policies. c. Unknown to the assistive personnel because the RN is responsible for outcomes. d. Clear and predictable.

D

Assertive communication

Direct Accurately expresses the person's feelings, beliefs, ideas, and opinions Respects self and others Encourages trust and teamwork Encourages others to express their opinions in an open and respectful atmosphere

Keys to successful negotiation include

Do some research. Clearly identify the objectives and goals. Avoid taking criticism personally. Avoid making personal attacks. Negotiate in good faith. Respect the other side's goals and objectives. Pre-plan the elements of the negotiation. Attend workshops or seminars on negotiation and bargaining.

Understanding Communication

Encoding and decoding Communication is interactive sharing of information. It requires a sender, a message, and a receiver. The receiver has the responsibility to listen to, process, and understand (encode) the information and then respond to the sender by giving feedback (decoding). Factors that interfere with the encoding process Sender factors Unclear speech Monotone voice Poor sentence structure Inappropriate use of terminology or jargon Lack of knowledge about the topic.Factors that interfere with the encoding process (cont'd) Receiver factors Lack of attention Prejudice and bias Preoccupation with another problem Physical factors such as pain, drowsiness, or impairment of the senses.Verbal communication: both the written and spoken word, constituting only about 7% of the communicated message. Nonverbal communication: makes up 58% of communication and includes body language, facial expressions, gestures, physical appearance, touch, and spatial territory (personal space). Paraverbal communication: makes up 35% of communication and includes vocal cues (tone, pauses), volume, and speed of speech. When the verbal, nonverbal, and paraverbal messages are congruent (relay the same information), then the message is more easily encoded and clearly understood.

Reasons nurses are uncomfortable with conflict

Fear of retaliation Fear of ridicule Fear of alienation of others Mistaken belief that they are unable to handle the conflict situation Feeling like they do not have the right to speak up Past negative experiences with conflict situations Family background and experiences Lack of education and skills on conflict resolution

Conflicting powers

In formal contract negotiation, there is an obvious power control conflict. Each side is reluctant to give up power or relinquish any control of key factors such as money or rights. The employees' group tries to gain some power from management and improve benefits for its members.

Rules for assertive communication

It takes practice. It requires a willingness to take risks. It requires a willingness to make mistakes and try again. It requires an understanding that not every outcome sought will be obtained. It requires strong self-esteem. Constant re-examination of outcomes helps assess progress. Goals for assertiveness growth need to be established beforehand. Others should be allowed to make mistakes.

Delegation and NCLEX

LPN's CANNOT: Do admission assessments Cannot give IV push meds (can do IVPB in NJ, not IV push) Cannot take care of pts with acute conditions (will be assigned chronic) Cannot take care of unstable patients UAP's/CNA's: lowest level of skill least complicated task look for most stable client look for chronic illness

Laws Governing Nursing

Nurse Practice Acts- each state gives authority to regulate the practice of nursing and can enforce of those laws NPA govern the nurses responsibility to delegate assignments must be based on a personnel's education, preparation, experience, and knowledge sterile or invasive procedures should be assigned to or supervised by RN (accessing of ports is only for RN)

Conflict resolution strategies

Strategy 1: Ignore the conflict Strategy 2: Confront the conflict Strategy 3: Postpone the conflict

Communication Styles

Submissive Aggressive-hostile

The Need for Good Communication

The nursing profession recognizes communication as one of the cornerstones of its practice. Nurses must be able to communicate with clients, family members, physicians, peers, and associates in an effective and constructive manner to achieve their goals of high-quality care. Good communication is essential for good leadership and management.

Negotiation

The process of give and take between individuals or groups with the goal of reaching an agreement acceptable to both sides. A specialized two-way communication skill in which individuals or groups with differing needs or ideas settle on a middle ground result that may not completely please either party. Negotiations may be formal or informal, hostile or friendly. Bargaining A special type of negotiation that is used when money-related issues are being discussed. Collective bargaining A formal type of negotiation. Used by groups of workers represented by a union or a negotiating body to solve workplace issues. Salaries, health-care benefits, safe work environment, hiring practices

Learn the skills

The purpose of all negotiation is to achieve a goal or objective. It is a skill that nurse managers must learn. All nurses should familiarize themselves with the skills.

True or False: Clients who are relatively stable and not likely to experience drastic changes in health-care status are the most suitable for delegation.

True

True or False: When nurses delegate nursing tasks, they are delegating nursing.

True

True or False: Anyone can learn to use an assertive communication style and develop assertiveness.

True

Mediation or arbitration

Used when the sides are unable to reach a resolution to their differences. Mediation is a form of alternative dispute resolution. The appointed mediator works with both sides to reach an agreement. The agreement is non-binding and either side can reject the settlement.

Arbitration

Usually the last step before the dispute is taken to court for litigation Can be either non-binding or binding Both parties must agree ahead of time to comply with whatever decision is reached by the arbitrator.

LPN

VS uncomplicated skills stable clients chronic diseases oral and IM medications

Select all that apply: What are important tasks for the RN to carry out prior to delegating a task to ancillary personnel? a. asses the patient b. know the knowledge level of the ancillary personnel c. check the list of tasks to see if it is appropriate for this person d. know the position description e. educate the assistive personnel in specific tasks f. check the status of the RNs malpractice insurance

a,b,d,e

Select all of the following which interfere with the encoding of a message from a sender to a receiver. a. Convoluted message b. Clear speech c. Monotone voice d. Use of jargon e. Understanding the information f. Preoccupation

a,c,d,f

8. An 11-year-old says, My parents dont like me. They call me stupid and say they wish I were never born. It doesnt matter what they think because I already know Im dumb. Which nursing diagnosis applies to this child? a. Chronic low self-esteem related to negative feedback from parents b. Deficient knowledge related to interpersonal skills with parents c. Disturbed personal identity related to negative self-evaluation d. Complicated grieving related to poor academic performance

a. Chronic low self-esteem related to negative feedback from parents The child has indicated a belief in being too dumb to learn. The child receives negative and demeaning feedback from the parents. The child has internalized these messages, resulting in a low self-esteem. Deficient knowledge refers to knowledge of health care measures. Disturbed personal identity refers to an alteration in the ability to distinguish between self and non-self. Grieving may apply, but a specific loss is not evident in the scenario. Low self-esteem is more relevant to the childs statements. PTS: 1 DIF: Cognitive Level: Apply (Application) REF: Page 2822 | Page 23 | Page 51 (Box 28-4) TOP: Nursing Process: Diagnosis/Analysis MSC: Client Needs: Psychosocial Integrity

11. A patient tells the nurse, My husband lost his job. Hes abusive only when he drinks too much. His family was like that when he was growing up. He always apologizes and regrets hurting me. What risk factor was most predictive for the husband to become abusive? a. History of family violence c. Abuse of alcohol b. Loss of employment d. Poverty

a. History of family violence An abuse-prone individual is an individual who has experienced family violence and was often abused as a child. This phenomenon is part of the cycle of violence. The other options may be present but are not as predictive. PTS: 1 DIF: Cognitive Level: Understand (Comprehension) REF: Page 532 | Page 535 | Page 545 (Box 28-7) TOP: Nursing Process: Assessment MSC: Client Needs: Psychosocial Integrity

2. A nurse assists a victim of intimate partner abuse to create a plan for escape if it becomes necessary. Which components should the plan include? Select all that apply. a. Keep a cell phone fully charged. b. Hide money with which to buy new clothes. c. Have the phone number for the nearest shelter. d. Take enough toys to amuse the children for 2 days. e. Secure a supply of current medications for self and children. f. Assemble birth certificates, Social Security cards, and licenses. g. Determine a code word to signal children when it is time to leave.

a. Keep a cell phone fully charged. c. Have the phone number for the nearest shelter. d. Take enough toys to amuse the children for 2 days. e. Secure a supply of current medications for self and children. g. Determine a code word to signal children when it is time to leave. The victim must prepare for a quick exit and so should assemble necessary items. Keeping a cell phone fully charged will help with access to support persons or agencies. Taking a large supply of toys would be cumbersome and might compromise the plan. People are advised to take one favorite small toy or security object for each child, but most shelters have toys to further engage the children. Accumulating enough money to purchase clothing may be difficult. PTS: 1 DIF: Cognitive Level: Apply (Application) REF: Page 543-544 (Box 28-6) TOP: Nursing Process: Planning MSC: Client Needs: Safe, Effective Care Environment

1. A 10-year-old cares for siblings while the parents work because the family cannot afford a babysitter. This child says, My father doesnt like me. He calls me stupid all the time. The mother says the father is easily frustrated and has trouble disciplining the children. The community health nurse should consider which resources as priorities to stabilize the home situation? Select all that apply. a. Parental sessions to teach childrearing practices b. Anger management counseling for the father c. Continuing home visits to give support d. A safety plan for the wife and children e. Placing the children in foster care

a. Parental sessions to teach childrearing practices b. Anger management counseling for the father c. Continuing home visits to give support Anger management counseling for the father is appropriate. Support for this family will be an important component of treatment. By the wifes admission, the family has deficient knowledge of parenting practices. Whenever possible, the goal of intervention should be to keep the family together thus, removing the children from the home should be considered a last resort. Physical abuse is not suspected, so a safety plan would not be a priority at this time. PTS: 1 DIF: Cognitive Level: Apply (Application) REF: Page 544-545 | Page 548 (Nursing Care Plan 28-1) TOP: Nursing Process: Planning MSC: Client Needs: Safe, Effective Care Environment

13. After treatment for a detached retina, a survivor of intimate partner abuse says, My partner only abuses me when I make mistakes. Ive considered leaving, but I was brought up to believe you stay together, no matter what happens. Which diagnosis should be the focus of the nurses initial actions? a. Risk for injury related to physical abuse from partner b. Social isolation related to lack of a community support system c. Ineffective coping related to uneven distribution of power within a relationship d. Deficient knowledge related to resources for escape from an abusive relationship

a. Risk for injury related to physical abuse from partner Risk for injury is the priority diagnosis because the partner has already inflicted physical injury during violent episodes. The other diagnoses are applicable, but the nurse must first address the patients safety. PTS: 1 DIF: Cognitive Level: Analyze (Analysis) REF: Page 537 (Box 28-4) | Page 541-542 TOP: Nursing Process: Diagnosis/Analysis MSC: Client Needs: Safe, Effective Care Environment

17. An older adult with Lewy body dementia lives with family. After observing multiple bruises, the home health nurse talked with the daughter, who became defensive and said, My mother often wanders at night. Last night she fell down the stairs. Which nursing diagnosis has priority? a. Risk for injury related to poor judgment, cognitive impairments, and inadequate supervision b. Wandering related to confusion and disorientation as evidenced by sleepwalking and falls c. Chronic confusion related to degenerative changes in brain tissue as evidenced by nighttime wandering d. Insomnia related to sleep disruptions associated with cognitive impairment as evidenced by wandering at night

a. Risk for injury related to poor judgment, cognitive impairments, and inadequate supervision The patient is at high risk for injury because of her confusion. The risk increases when caregivers are unable to give constant supervision. Insomnia, chronic confusion, and wandering apply to this patient however, the risk for injury is a higher priority. PTS: 1 DIF: Cognitive Level: Analyze (Analysis) REF: Page 537 (Box 28-4) | Page 541-542 TOP: Nursing Process: Diagnosis/Analysis MSC: Client Needs: Safe, Effective Care Environment

3. A community health nurse visits a family with four children. The father behaves angrily, finds fault with the oldest child, and asks twice, Why are you such a stupid kid? The wife says, I have difficulty disciplining the children. Its so frustrating. Which comments by the nurse will facilitate an interview with these parents? Select all that apply. a. Tell me how you discipline your children. b. How do you stop your baby from crying? c. Caring for four small children must be difficult. d. Do you or your husband ever spank your children? e. Calling children stupid injures their self-esteem.

a. Tell me how you discipline your children. b. How do you stop your baby from crying? c. Caring for four small children must be difficult. An interview with possible abusing individuals should be built on concern and carried out in a nonthreatening, nonjudgmental way. Empathetic remarks are helpful in creating rapport. Questions requiring a descriptive response are less threatening and elicit more relevant information than questions that can be answered by yes or no.

1. Which comment by the nurse would best support relationship building with a survivor of intimate partner abuse? a. You are feeling violated because you thought you could trust your partner. b. Im here for you. I want you to tell me about the bad things that happened to you. c. I was very worried about you. I knew you were living in a potentially violent situation. d. Abusers often target people who are passive. I will refer you to an assertiveness class.

a. You are feeling violated because you thought you could trust your partner. The correct option uses the therapeutic technique of reflection. It shows empathy, an important nursing attribute for establishing rapport and building a relationship. None of the other options would help the patient feel accepted. PTS: 1 DIF: Cognitive Level: Apply (Application) REF: Page 543 | Page 546 TOP: Nursing Process: Implementation MSC: Client Needs: Psychosocial Integrity

19. An adult has a history of physical violence against family when frustrated, followed by periods of remorse after each outburst. Which finding indicates a successful plan of care? The adult: a. expresses frustration verbally instead of physically. b. explains the rationale for behaviors to the victim. c. identifies three personal strengths. d. agrees to seek counseling.

a. expresses frustration verbally instead of physically. The patient will have developed a healthier way of coping with frustration if it is expressed verbally instead of physically. The incorrect options do not confirm achievement of outcomes. PTS: 1 DIF: Cognitive Level: Apply (Application) REF: Page 541-542 | Page 547-548 TOP: Nursing Process: Evaluation MSC: Client Needs: Psychosocial Integrity

5. The parents of a 15-year-old seek to have this teen declared a delinquent because of excessive drinking, habitually running away, and prostitution. The nurse interviewing the patient should recognize these behaviors often occur in adolescents who: a. have been abused. c. have eating disorders. b. are attention seeking. d. are developmentally delayed.

a. have been abused. Self-mutilation, alcohol and drug abuse, bulimia, and unstable and unsatisfactory relationships are frequently seen in teens who are abused. These behaviors are not as closely aligned with any of the other options. PTS: 1 DIF: Cognitive Level: Understand (Comprehension) REF: Page 533 (Box 28-1) TOP: Nursing Process: Assessment MSC: Client Needs: Psychosocial Integrity

RNs

admission assessment IV meds Blood products Care plan Client Teaching Unstable clients acute diseases

Legality of delegation

as charge nurse you are always responsible power of delegation is restricted to professionals who are licensed and governed by statutory practice acts

Select all that apply: What are positive aspects of delegation? a. It relieves the RN from responsibility for a number of nursing tasks. b. It allows more care to be given to more patients. c. It leaves accountability and decision making with ancillary personnel. d. It motives ancillary personnel to seek more education. e. Frees the RN from lower level time consuming tasks. f. Allows the RN more time to plan for care.

b,d,e,f

16. An older adult with Alzheimers disease lives with family in a rural area. During the week, the person attends a day care center while the family is at work. In the evenings, members of the family provide care. Which factor makes this patient most vulnerable to abuse? a. Multiple caregivers c. Living in a rural area b. Alzheimers disease d. Being part of a busy family

b. Alzheimers disease Older adults are at high risk for violence, particularly those with cognitive impairments. The other characteristics are not identified as placing an individual at high risk. PTS: 1 DIF: Cognitive Level: Understand (Comprehension) REF: Page 534-535 TOP: Nursing Process: Assessment MSC: Client Needs: Safe, Effective Care Environment

3. What feelings are most commonly experienced by nurses working with abusive families? a. Outrage toward the victim and discouragement regarding the abuser b. Helplessness regarding the victim and anger toward the abuser c. Unconcern for the victim and dislike for the abuser d. Vulnerability for self and empathy with the abuser

b. Helplessness regarding the victim and anger toward the abuser Intense protective feelings, helplessness, and sympathy for the victim are common emotions of a nurse working with an abusive family. Anger and outrage toward the abuser are common emotions of a nurse working with an abusive family. PTS: 1 DIF: Cognitive Level: Understand (Comprehension) REF: Page 540-541 (Table 28-3) TOP: Nursing Process: Assessment MSC: Client Needs: Psychosocial Integrity

18. An older woman diagnosed with Alzheimers disease lives with family and attends day care. After observing poor hygiene, the nurse talked with the caregiver. This caregiver became defensive and said, It takes all my energy to care for my mother. Shes awake all night. I never get any sleep. Which nursing intervention has priority? a. Teach the caregiver about the effects of sundowners syndrome. b. Secure additional resources for the mothers evening and night care. c. Support the caregiver to grieve the loss of the mothers cognitive abilities. d. Teach the family how to give physical care more effectively and efficiently.

b. Secure additional resources for the mothers evening and night care. The patients caregivers were coping with care until the patient began to stay awake at night. The family needs assistance with evening and night care to resume their pre-crisis state of functioning. Secondary prevention calls for the nurse to mobilize community resources to relieve overwhelming stress. The other interventions may then be accomplished. PTS: 1 DIF: Cognitive Level: Apply (Application) REF: Page 546-547 TOP: Nursing Process: Planning MSC: Client Needs: Safe, Effective Care Environment

4. Which rationale best explains why a nurse should be aware of personal feelings while working with a family experiencing family violence? a. Self-awareness enhances the nurses advocacy role. b. Strong negative feelings interfere with assessment and judgment. c. Strong positive feelings lead to healthy transference with the victim. d. Positive feelings promote the development of sympathy for patients.

b. Strong negative feelings interfere with assessment and judgment. Strong negative feelings cloud the nurses judgment and interfere with assessment and intervention, no matter how well the nurse tries to cover or deny feelings. Strong positive feelings lead to over-involvement with victims rather than healthy transference. PTS: 1 DIF: Cognitive Level: Understand (Comprehension) REF: Page 540-541 TOP: Nursing Process: Planning MSC: Client Needs: Psychosocial Integrity

14. A survivor of physical spousal abuse was treated in the emergency department for a broken wrist. This patient said, Ive considered leaving, but I made a vow and I must keep it no matter what happens. Which outcome should be met before discharge? The patient will: a. facilitate counseling for the abuser. b. name two community resources for help. c. demonstrate insight into the abusive relationship. d. reexamine cultural beliefs about marital commitment.

b. name two community resources for help. The only outcome indicator clearly attainable within this time is for staff to provide the victim with information about community resources that can be contacted. Development of insight into the abusive relationship and reexamining cultural beliefs will require time. Securing a restraining order can be accomplished quickly but not while the patient is in the emergency department. Facilitating the abusers counseling may require weeks or months. PTS: 1 DIF: Cognitive Level: Apply (Application) REF: Page 539 | Page 541-542 TOP: Nursing Process: Outcomes Identification MSC: Client Needs: Safe, Effective Care Environment

Followership

believes in traditional social hierarchy identifies as a follower a leader cannot practice leadership if there are not followers follower is not negative, followers have great deal of power and influence over leader's success

20. Which referral will be most helpful for a woman who was severely beaten by intimate partner, has no relatives or friends in the community, is afraid to return home, and has limited financial resources? a. A support group c. A womens shelter b. A mental health center d. Vocational counseling

c. A womens shelter Because the woman has no safe place to go, referral to a shelter is necessary. The shelter will provide other referrals as necessary. PTS: 1 DIF: Cognitive Level: Apply (Application) REF: Page 537 | Page 544 (Box 28-6) TOP: Nursing Process: Implementation MSC: Client Needs: Safe, Effective Care Environment

2. An 11-year-old reluctantly tells the nurse, My parents dont like me. They said they wish I was never born. Which type of abuse is likely? a. Sexual c. Emotional b. Physical d. Economic

c. Emotional Examples of emotional abuse include having an adult demean a childs worth, frequently criticize, or belittle the child. No data support physical battering or endangerment, sexual abuse, or economic abuse. PTS: 1 DIF: Cognitive Level: Understand (Comprehension) REF: Page 532 | Page 538-539 TOP: Nursing Process: Assessment MSC: Client Needs: Psychosocial Integrity

12. An adult tells the nurse, My partner abuses me when I make mistakes, but I always get an apology and a gift afterward. Ive considered leaving but havent been able to bring myself to actually do it. Which phase in the cycle of violence prevents this adult from leaving? a. Tension-building c. Honeymoon b. Acute battering d. Stabilization

c. Honeymoon The honeymoon stage is characterized by kind, loving behaviors toward the abused spouse when the perpetrator feels remorseful. The victim believes the promises and drops plans to leave or seek legal help. The tension-building stage is characterized by minor violence in the form of abusive verbalization or pushing. The acute battering stage involves the abuser beating the victim. The violence cycle does not include a stabilization stage. PTS: 1 DIF: Cognitive Level: Understand (Comprehension) REF: Page 534 TOP: Nursing Process: Assessment MSC: Client Needs: Safe, Effective Care Environment

15. An older adult with Lewy body dementia lives with family and attends a day care center. A nurse at the day care center noticed the adult had a disheveled appearance, strong odor of urine, and bruises on the limbs and back. What type of abuse might be occurring? a. Psychological c. Physical b. Financial d. Sexual

c. Physical Lewy body dementia results in cognitive impairment. The assessment of physical abuse would be supported by the nurses observation of bruises. Physical abuse includes evidence of improper care as well as physical endangerment behaviors, such as reckless behavior toward a vulnerable person that could lead to serious injury. No data substantiate the other options. PTS: 1 DIF: Cognitive Level: Understand (Comprehension) REF: Page 532 | Page 535 | Page 537 (Box 28-4) TOP: Nursing Process: Assessment MSC: Client Needs: Safe, Effective Care Environment

6. What is a nurses legal responsibility if child abuse or neglect is suspected? a. Discuss the findings with the childs parent and health care provider. b. Document the observation and suspicion in the medical record. c. Report the suspicion according to state regulations. d. Continue the assessment.

c. Report the suspicion according to state regulations. Each state has specific regulations for reporting child abuse that must be observed. The nurse is a mandated reporter. The reporter does not need to be sure that abuse or neglect occurred, only that it is suspected. Speculation should not be documented, only the facts. PTS: 1 DIF: Cognitive Level: Understand (Comprehension) REF: Page 543 TOP: Nursing Process: Implementation MSC: Client Needs: Safe, Effective Care Environment

7. Several children are seen in the emergency department for treatment of various illnesses and injuries. Which assessment finding would create the most suspicion for child abuse? The child who has: a. complaints of abdominal pain. c. bruises on extremities. b. repeated middle ear infections. d. diarrhea.

c. bruises on extremities. Injuries such as immersion or cigarette burns, facial fractures, whiplash, bite marks, traumatic injuries, bruises, and fractures in various stages of healing suggest the possibility of abuse. In older children, vague complaints such as back pain may also be suspicious. Ear infections, diarrhea, and abdominal pain are problems that were unlikely to have resulted from violence. PTS: 1 DIF: Cognitive Level: Apply (Application) REF: Page 537-538 | Page 545 (Box 28-7) TOP: Nursing Process: Assessment MSC: Client Needs: Safe, Effective Care Environment

Authoritarian

controlling, directive, autocratic Primary objective: get job done Primary motivation: power and control strict, dictatorial "my way or highway" no regard for feelings or needs of group benevolent: kind and caring but "if I give you something, you owe me" Leader makes all decisions

10. A young adult has recently had multiple absences from work. After each absence, this adult returned to work wearing dark glasses and long-sleeved shirts. During an interview with the occupational health nurse, this adult says, My partner beat me, but it was because I did not do the laundry. What is the nurses next action? a. Call the police. c. Call the adult protective agency. b. Arrange for hospitalization. d. Document injuries with a body map.

d. Document injuries with a body map. Documentation of injuries provides a basis for possible legal intervention. In most states, the abused adult would need to make the decision to involve the police. Because the worker is not an older adult and is competent, the adult protective agency is unable to assist. Admission to the hospital is not necessary. PTS: 1 DIF: Cognitive Level: Apply (Application) REF: Page 540-541 | Page 548-549 (Nursing Care Plan 28-1) TOP: Nursing Process: Implementation MSC: Client Needs: Safe, Effective Care Environment

9. An adult has recently been absent from work for 3-day periods on several occasions. Each time, the individual returned wearing dark glasses. Facial and body bruises were apparent. What is occupational health nurses priority assessment? a. Interpersonal relationships c. Socialization skills b. Work responsibilities d. Physical injuries

d. Physical injuries The individual should be assessed for possible battering. Physical injuries are abuse indicators and are the primary focus for assessment. No data support the other options. PTS: 1 DIF: Cognitive Level: Apply (Application) REF: Page 537-538 | Page 545 (Box 28-7) TOP: Nursing Process: Assessment MSC: Client Needs: Safe, Effective Care Environment

Nurse practice acts

each state has a practice and each facility has a policy

UAP

feeding basic hygiene basic skills stable clients chronic diseases ambulation

Characteristics of effective leaders

high level of intelligence and skill self motivated communicate well confidence, assertiveness creativity persistence stress tolerance willing to take risks accept criticism

Assignment

made to CNAs and LPNs, not same scope of practice

Kentucky Board of Nursing

mission is to protect the public from nurse regulates what we can do and what we can't develop and enforce state laws governing the safe practice of nursing, nursing education, and credentialing

Democratic style

more supportive, participative, trasnformational Primary objective: get the job done Promary motivation: involvement and eneganemtn Hallmarks...

Leadership Style (Laissez-Faire)

permissive, nondirective, passive little planning, minimal decision making, lack of involvement by leader wors best when members of group have the same education as leader and leader performs the same tasks

5 rights to delegation

pg 401 right task right person right direction right supervision right circumstance

Delegation

transfer of duty to another RN, same scope of practice

Leadership v management

two types of authority Formal: power, what comes with position (budget) Informal: power that comes as result of others granting support (who is best stick, best to talk with upset pt) good leadership may not be good in management position