Safety and Infection Control

The risk for injury during an attack of Ménière's disease is high. The nurse should instruct the client to take which immediate action when experiencing vertigo? -"Place your head between your knees." -"Concentrate on rhythmic deep breathing." -"Close your eyes tightly." -"Assume a reclining or flat position."

A: "Assume a reclining or flat position." Rationale: The client needs to assume a safe and comfortable position during an attack, which may last several hours. The client's location when the attack occurs may dictate the most reasonable position. Ideally, the client should lie down immediately in a reclining or flat position to control the vertigo. The danger of a serious fall is real. Placing the head between the knees will not help prevent a fall and is not practical because the attack may last several hours. Concentrating on breathing may be a useful distraction, but it will not help prevent a fall. Closing the eyes does not help prevent a fall.

A nurse is caring for a 14-year-old client who was admitted with cellulitis and has been ordered warm compresses. The nurse delegates the treatment to the unlicensed assistive personnel (UAP). The compress causes a first-degree burn to the area. Which actions should the nurse initiate? -Initiate a disciplinary action toward the UAP -Complete an incident report regarding the event -Notify the healthcare provider of the injury -Place ice compresses on the injured area -Document the injury describing the UAPs actions

A: -Complete an incident report regarding the event -Notify the healthcare provider of the injury Rationale: Based on the rules of delegation, this should have been delegated to a licensed practical/vocational nurse, not unlicensed assistive personnel (UAP). The nurse is accountable for the action. The nurse needs to complete an incident report and notify the healthcare provider. Ice is not applied to burn wounds due to increased cellular injury. An incident report factually reports everyone involved and objectively describes actions.

Following an education session on proper hand hygiene, the nurse educator observes a nurse washing hands before entering a client's room. Which observation would alert the nurse educator to the need for further education? -The nurse dries from finger tips down toward elbows. -The nurse dries from forearms up toward fingers. -The nurse keeps hands lower than elbows while washing. -The nurse uses at least 3 to 5 mL of liquid soap.

A: The nurse dries from forearms up toward fingers. Rationale: Hand hygiene procedures involve drying from the fingers toward the forearm and discarding the paper towel. The other options should be included in hand hygiene practices.

While making rounds, the nurse finds a client with chronic obstructive pulmonary disease sitting in a wheelchair, slumped over a lunch tray. After determining the client is unresponsive and calling for help, what should the nurse do next? -Push the "code blue" (emergency response) button. -Call the rapid response team. -Open the client's airway. -Call for a defibrillator.

A: Open the client's airway. Rationale: The nurse has already called for help and established unresponsiveness so the first action is to open the client's airway; opening the airway may result in spontaneous breathing and will help the nurse determine whether or not further intervention is required. Pushing the "code blue" button may not be the appropriate action if the client is breathing and becomes responsive once the airway is open. A quick assessment upon opening the client's airway will help the nurse to determine if the rapid response team is needed. Calling for a defibrillator may not be the necessary or appropriate action once the client's airway has been opened.

The nurse is planning care for a client who has an allergy to latex. What intervention would be the priority for the nurse to include in the plan of care? -Avoid using oil-based lotions on the client's skin. -Ensure client's roommate does not have an indwelling latex urinary catheter. -Place latex-free, powder-free gloves at client's bedside. -Place client in private room with clear signage about allergy.

A: Place latex-free, powder-free gloves at client's bedside. Rationale: Latex-free, powder-free gloves reduce the risk of respiratory exposure to latex. Having them conveniently located will enhance staff adherence, so this is the most important intervention. Using oil-based hand lotion should be avoided when wearing latex gloves because this increases risk of latex breakdown and can increase latex exposure for the person wearing the gloves. However, the client can have oil-based lotions applied to the skin as this is not contraindicated. Obviously, the nurse would wear latex-free gloves for application, or no gloves at all if no contact with body fluids is expected. Having a roommate with a latex catheter does not pose a risk of direct exposure for the client. Clients with latex allergies should have clear signage but do not require a private room.

A client who has an abdominal dressing has asked to use the urinal. A nurse drops a clean glove on the floor while attempting to don gloves. In which order, from first to last, should the nurse proceed? 1 Apply new, clean gloves. 2 Assess the client's surgical dressing. 3 Reposition the client's urinal. 4 Dispose of the glove on the floor.

A: -Apply new, clean gloves. -Assess the client's surgical dressing. -Reposition the client's urinal. -Dispose of the glove on the floor. Rationale: The nurse should always work from least contaminated to most contaminated area. If the nurse picks up and disposes of the glove on the floor, the hands are contaminated and the nurse will need to repeat hand hygiene before caring for the client. The nurse should first put on a new pair of clean gloves and then assess the client's surgical dressing. The nurse can next assist the client with using the urinal, and last, the nurse can pick up and dispose of the glove on the floor. It is more time efficient to dispose of fallen objects when all client care is complete unless the fallen object is required to proceed with client care.

The nurse sees a client walking in the hallway who begins to have a seizure. What should the nurse do in order of priority from first to last? All options must be used. 1 Ease the client to the floor. 2 Maintain a patent airway. 3 Obtain vital signs. 4 Record the seizure activity observed.

A: -Ease the client to the floor. -Maintain a patent airway. -Obtain vital signs. -Record the seizure activity observed. Rationale: To protect the client from falling, the nurse first should ease the client to the floor. It is important to protect the head and maintain a patent airway since altered breathing and excessive salivation can occur. The assessment of the postictal period should include level of consciousness and vital signs. The nurse should record details of the seizure once the client is stable. The events preceding the seizure, timing with descriptions of each phase, body parts affected and sequence of involvement, and autonomic signs should be recorded.

A hospital safety officer is evaluating nurses' responses to potential safety hazards. Which employee actions are appropriate for the situation? Select all that apply. -taking small steps with feet shoulder length apart when walking on wet surfaces -walking under a ladder that is braced against a wall in the hallway -moving an unlabeled backpack found in a bathroom during a bomb alert -removing clients from the area where a fire is reported -using tongs to place a dislodged radioactive device in a lead container

A: -taking small steps with feet shoulder length apart when walking on wet surfaces -removing clients from the area where a fire is reported -using tongs to place a dislodged radioactive device in a lead container Rationale: There are a number of situations that could compromise safety where an appropriate response will minimize risk. People should not walk under ladders, move unidentified objects during a bomb threat, or directly touch radiation sources. Clients should be safe before an employee starts to fight a fire. Wet conditions make footing slippery, so if it is necessary to walk on a wet surface the person should use a wide base of support and take small steps.

A client is brought to the psychiatric clinic by family members, who tell the admitting nurse that the client repeatedly drives while intoxicated despite their pleas for the client to stop doing so. During an interview with the nurse, which client statement most strongly supports a diagnosis of a substance use disorder? -"I use drinking as a means for staying social with some friends." -"I spend only half of my paycheck at the bar. My friends spend more!" -"I just drink to relax after work because I have a very stressful job." -"I have been arrested for drunk driving three times, but I never had an accident."

A: "I have been arrested for drunk driving three times, but I never had an accident." Rationale: Addictive behavior that meets the criteria for a substance use disorder involves a maladaptive pattern of such use, indicated either by recurrent use in dangerous situations (for example, while driving) or by continued use despite knowledge of having a persistent or recurrent social, legal, occupational, psychological, or physical problem caused or exacerbated by use. Although additional criteria for this disorder include a need for increasing amounts of the substance to achieve intoxication, increased time and money spent on the substance, inability to fulfill role obligations, and typical withdrawal symptoms, the recurrent use of alcohol while driving is the strongest indicator in this scenario. The statement about the use of alcohol for socialization or as a means to relax do not indicate alcohol is interfering in the client's functioning and are therefore not strong indicators for addiction.

The nurse is discharging a baby with clubfoot who has had a cast applied. The nurse should provide additional teaching to the parents if they make which statement? -"I should call if I see changes in the color of the toes under the cast." -"I should use a pillow to elevate my child's foot as he sleeps." -"My baby will need a series of casts to fix her foot." -"Having a cast should not prevent me from holding my baby."

A: "I should use a pillow to elevate my child's foot as he sleeps." Rationale: Elevating the extremity at different points during the day is helpful to prevent edema, but pillows should not be used in the crib because they increase the risk of sudden infant death syndrome (SIDS). A change in the color of the toes is a sign of impaired circulation and requires medical evaluation. Children typically need a series of 5 to 10 casts to correct the deformity. Infants with club feet still need frequent holding like any other newborn.

The parents of a child who requires skeletal traction are unable to visit their child for more than 1 hour a day because there are five other children at home and both parents work outside of the home. The nurse recognizes expressions of guilt in both parents. To help alleviate this guilt, the nurse should make which statement? -"I am sure you feel guilty about not being able to visit often." -"It is important that you visit even for 1 hour." -"Not all parents can stay all the time." -"Perhaps you could take turns visiting for a bit longer."

A: "It is important that you visit even for 1 hour." Rationale: Stressing the importance of the parents' visiting when they can helps to alleviate the guilt they feel. It allows the parents to feel that they are doing what they can. Acknowledging the guilt gives the parents an opportunity to talk about it but does not help alleviate it. Comparing the parents with other parents does not alleviate guilt feelings. The parents need reinforcement that what they are doing is appropriate. Suggesting that the parents take turns visiting implies that they should feel guilty because they may not be doing all they could.

When talking with 10-year-old children about death, the nurse should incorporate which guidelines? Select all that apply. -Logical explanations are not appropriate. -The children will be curious about the physical aspects of death. -The children will know that death is inevitable and irreversible. -Attitudes of the adults in their lives will influence the children. -Teaching about death and dying should not start before age 11 years. -Teach children that death is the same as going to sleep as a way of relieving fear.

A: -The children will be curious about the physical aspects of death. -The children will know that death is inevitable and irreversible. -Attitudes of the adults in their lives will influence the children. Rationale: By age 10 years, most children know that death is universal, inevitable, and irreversible. School-age children are curious about the physical aspects of death and may wonder what happens to the body. Their cognitive abilities are advanced and they respond well to logical explanations. They should be encouraged to ask questions. The adults in their environment influence their attitudes toward death. Adults should be encouraged to include children in the family rituals and should be prepared to answer questions that might seem shocking. Teaching about death should begin early in childhood. Comparing death to sleep can be frightening for children and cause them to fear falling asleep.

A nurse is caring for a newly admitted client who appears anxious and fearful. The client states, "I do not trust any of you. Stay away from me!" Which nursing actions would be beneficial? Select all that apply. -The nurse would mirror the client's mannerisms and anxiety level. -The nurse would agree saying that it is hard to trust people these days -The nurse would calmly state, "I am here to help you. What can I do?" -The nurse would state, "Tell me why you do not trust me." -The nurse would sit quietly near the client and respond to questions. -The nurse would notify the health care provider and ask for a sedative.

A: -The nurse would calmly state, "I am here to help you. What can I do?" -The nurse would state, "Tell me why you do not trust me." -The nurse would sit quietly near the client and respond to questions. Rationale: When providing care to a new client with anxiety and fear issues, the nurse must first reduce client anxiety and develop a trusting relationship. Obtaining the client's perspective by asking an open ended question allows the client to elaborate and reduce client anxiety. Also, offering a sense of self to the client with phrases such as "What can I do?" or sitting quietly near the client, allows the client to see the calmness of the nurse and provides an opportunity to seek help when ready. Mirroring (reflecting) the anxiety of the client raises client anxiety. Agreeing with the client inappropriately validates the client's feeling of mistrust which raises anxiety. Asking for a sedative (chemical restraints) prior to providing therapeutic nursing communication is not acceptable.

A client is hospitalized for depression. The client calmly tells the nurse that they cut their foot and need a bandage. The client reveals a 2 cm by 6 cm (1 in by 2.5 in) bloody triangle on the right insole that appeared to be a self-inflicted wound with a sharp instrument. Which action would be the priority for the nurse to take? -Report the client's injury the client's physician. -Assess the injury and assess for any other self-inflicted wounds in a matter-of-fact manner. -Ask the client about their feelings leading up to the self-harm. -Remove all dangerous items from the environment.

A: Assess the injury and assess for any other self-inflicted wounds in a matter-of-fact manner. Rationale: The nurse would first assess the client and treat the injury in a matter-of-fact manner before reporting to the physician. Asking the client about their feelings is correct; however, this would not be the first step. Removing all dangerous items from the environment would be the next step after assessing the extent of the client's injury.

The nurse is caring for a critically ill client who informs the nurse that there is a conflict between the client's spiritual beliefs and a proposed health option. What is the nurse's role in this situation? -Assist the client in obtaining information to make an informed decision. -Encourage the client to pray for clarity on the matter and offer support. -Inform the client's healthcare provider of the client's concerns. -Provide examples of ways clients handle spiritual and care planning conflicts.

A: Assist the client in obtaining information to make an informed decision. Rationale: The nurse's role in resolving conflicts between spiritual beliefs and treatments is to assist the client in obtaining the information needed to make an informed decision and to support the client's decision making. Telling the client to pray does not assist the client in the decision-making process. The healthcare provider does not manage client decisions when it comes to spiritual beliefs. Offering examples of other clients does not help this client.

A client has soft wrist restraints to prevent the client from pulling out the nasogastric tube. Which nursing intervention should be implemented while the restraints are on the client? -Instruct the client not to move while the restraints are in place. -Remove the restraints every 4 hours to provide skin care. -Secure the restraints to side rails of the bed. -Check on the client every 30 minutes while the restraints are on.

A: Check on the client every 30 minutes while the restraints are on. Rationale: The application of restraints places the client in a vulnerable, confined position. The nurse should check on the client every 30 minutes while restrained to make sure that the client is safe. The client should be able to move while the restraints are in place. The restraints should be removed every 2 hours to provide skin care and exercise the extremities. Restraints should not be secured to the side rails; they should be secured to the movable bed frame so that when the bed is adjusted the restraints will not be pulled too tightly.

The night nurse has completed the change of shift report. As the day nurse makes rounds on a postpartum client receiving magnesium sulfate, it is noted the client developed significantly elevated blood pressure during the past shift. Further assessment reveals the magnesium sulfate rate is infusing well below the prescribed rate. In addition to adjusting the infusion rate and notifying the health care provider (HCP), what is the most important action by the nurse? -Complete an incident report. -Discuss the matter with the night nurse the next time she works. -Ask the charge nurse if an incident report is necessary. -Evaluate the client's BP for 4 hours before making decision.

A: Complete an incident report Rationale: Safety is the highest priority, and a nursing error has occurred. If the day nurse decides to tell the night nurse, the timing of the notification will be up to the nurse initiating the incident report. The nurse should confer with the charge nurse concerning the incident, but completion of the report is required. Waiting for several hours to initiate the report based on changes in client data and assessment is not an ethical or professional decision and should not be considered; again, safety is the highest priority.

A client with functional neurologic symptom disorder reports sudden onset blindness. The nurse examines the client's health record for evidence of what most likely causative factor for the client's symptoms? -a family history of major depression -exposure to a traumatic event -noncompliance with a psychotropic medication regimen -daily use of antianxiety agents and alcoholic beverages

A: exposure to a traumatic event Rationale: Functional neurologic symptom disorder is characterized by alteration or loss of physical function with no physiological basis; the client's symptoms result from psychological conflict. For example, a client may report blindness after having observed a distressing act, such as seeing a loved one die violently. A family history of depression, noncompliance with drug therapy, and daily use of antianxiety agents and alcohol don't cause this disorder.

When performing a postoperative assessment on a client who has undergone surgery to manage increased intracranial pressure (ICP), a nurse notes an ICP reading of 0 mm Hg. Which action should the nurse perform first? -Check the equipment. -Contact the physician to review the care plan. -Continue the assessment because no actions are indicated at this time. -Document the reading because it reflects that the treatment has been effective.

A: Check the equipment. Rationale: A reading of 0 mm Hg indicates equipment malfunction. The nurse should check the equipment and report problems. Normal and stable ICP values are less than 15 mm Hg. Some pressure is always present in the cranial vault. The nurse shouldn't contact the physician to review the care plan at this time. The nurse needs to complete the assessment of the client and equipment before making a report to the physician.

A charge nurse learns of another nurse who has had two unsuccessful attempts at starting a peripheral IV for a child. What is the most appropriate action by the charge nurse? -Speak to the nurse about the situation and offer to start the child's IV. -Allow the nurse another attempt under supervision before offering to start the IV. -After a third unsuccessful attempt by the nurse, contact the supervisor to start the IV. -Allow for a total of four IV attempts by the nurse, then contact the IV insertion team.

A: Speak to the nurse about the situation and offer to start the child's IV. Rationale: When starting a peripheral IV for a child, no more than two attempts at insertion should be made by one nurse. Therefore, the charge nurse should interrupt the nurse and offer to start the IV. In children, total attempts at IV insertion should be limited to four because multiple unsuccessful attempts cause the child unnecessary pain, delay treatment, and increase the risk of complications.

The nurse is instructing the spouse of a client who had an incision and drainage procedure for an abscess how to care for the wound at home. What information should the nurse give the spouse about cleaning the wound? -Clean the incision and drainage sites simultaneously. -Clean from the incision site to the drainage site. -Clean from the drainage site to the incision site. -Clean both sites independently.

A: Clean both sites independently. Rationale: The sites should be treated as separate sites to avoid cross contamination. This adheres to the principle of cleaning from the least contaminated area to the most contaminated area. Each site is considered a separate area for wound care.

A nurse applies standard precautions when caring for a client with human immunodeficiency virus (HIV). The nurse takes what action when applying standard precautions? -wearing gloves when helping client dress -providing a dedicated commode at bedside -wearing gloves for providing mouth care -gowning and gloving for intravenous insertion

A: wearing gloves for providing mouth care Rationale: The client's HIV status is irrelevant to the application of standard precautions, and the client should not be treated differently becuase of this diagnosis. A healthcare worker wears gloves when contact with any client's blood or body fluids is anticipated, such as when providing mouth care. Such barrier protection helps prevent viruses from entering the bloodstream. When assisting a client to get dressed, gloves are not required unless contact with blood is anticipated. Gowns are not required for intravenous insertion, and a dedicated commode is not part of standard precautions.

A nurse is caring for a 14-year-old adolescent who states, "No one understands me." Which statement by the nurse best demonstrates empathy? -"Explain why you think no one understands you. How can adults help?" -"Tell me about a time you felt your parents were understanding." -"Let's talk about your future plans and which courses you enjoy." -"It's difficult to be a teenager. Tell me more about your experiences."

A: Rationale: Empathy is the ability to put oneself in another's place and experience a feeling as that person is experiencing it. The correct answer acknowledges the adolescent's feelings and conveys an understanding without intimidating the client. Asking how adults can help and reflecting on parental understanding or favorite coursework is helpful overall but does not demonstrate empathy for the client.

The emergency department nurse is assessing a client with reports of right-sided dull, abdominal and flank pain, nausea, and vomiting. The client's temperature is 101.2° F (38.4° C), pain is 10 out of 10, and rebound tenderness is exhibited. The healthcare provider orders: VS q 30 min, CBC, morphine 2 mg IM q 4 hours, regular diet, and enemas until clear. Which orders should the nurse question? Select all that apply. -vital signs -enemas until clear -CBC -morphine -regular diet

A: enemas until clear regular diet Rationale: The nurse should question the enema order, as enema could cause the appendix to burst. If the condition is an appendicitis, the client should be NPO for possible surgery so a regular diet should not be given to the client. It is important that the client does not take laxatives or enemas to relieve constipation as these medications could cause the appendix to burst.

The children of an elderly client who has suffered an ischemic stroke have informed the nurse that an herbalist will be coming to their parent's bedside tomorrow to make recommendations for client's care. Which considerations should the nurse prioritize in light of the practitioner's planned visit? -ensuring any complementary therapies are safe when combined with his prescribed therapy -identifying whether the family would prefer to pursue alternative or conventional treatment for their parent -ensuring that the care team does not impose their beliefs on the family or the complementary practitioner -taking measures to prevent cultural conflict when the practitioner comers to the hospital

A: ensuring any complementary therapies are safe when combined with his prescribed therapy Rationale: While it is important for the nurse and the other members of the care team to ensure that stereotypes or cultural imposition do not exist, the priority in all aspects of care is safety. Consequently, potential interactions between the complementary therapies and conventional hospital treatments are a priority. The family should not be required to forgo conventional treatment to pursue some aspects of culturally based, complementary care.

A nurse is teaching a client stress management. Which techniques would be considered adaptive coping skills? Select all that apply. -maintain control of my life -set realistic goals for each day -practice relaxation techniques -balance sleep, rest, and exercise -try to eliminate total anxiety

A: -set realistic goals for each day -practice relaxation techniques -balance sleep, rest, and exercise Rationale: Stress affects everyone. So it is important for the nurse to assist the client to deal with the present stress and to build the ability to cope with future problems. Adaptive coping skills assist in this way and can assist the client in setting goals, practicing relaxation and balancing rest, sleep, and exercise. It is not possible to control one's life or totally eliminate anxiety. Things happen each day that are out of one's control, and anxiety results. The idea is to be able to deal with life as it comes.

Two spouses seek emergency crisis intervention because the first spouse slapped the second spouse repeatedly the night before. The first spouse reports a childhood marred by an abusive relationship with a parent. To assess for the likelihood of further violence and abuse, the nurse should determine that the first spouse: -has moderate impulse control. -trusts the spouse and supports the spouse's independence. -has learned violence as an acceptable behavior. -feels secure in the relationship with the spouse.

A: has learned violence as an acceptable behavior. Rationale: Family violence is usually a learned behavior. This couple is at risk for further violence. Poor, not moderate, impulse control indicates a risk for more violence. Violent people generally are jealous and possessive and feel insecure in their relationships.

A client in the intensive care unit has a nursing diagnosis of Social isolation. Which action would the nurse include in the care plan? -removing all personal belongings from the bedside -involving the client and family in planning care -providing the client with detailed explanations of condition and treatment -allowing the family to visit only when the client asks to see them

A: involving the client and family in planning care Rationale: For a client with a nursing diagnosis of Social isolation, interventions include involving the family and the client in planning care and encouraging visits from family members and friends. Banning personal belongings from the bedside would increase the client's feelings of isolation. The nurse would provide simple, not detailed, explanations to the client and family because stress may have diminished their comprehension. The nurse would encourage the family to visit as often as the client's condition permits.

A nurse is preparing a client for cardiac catheterization. What is the nurse's priority assessment? -Weight and height -Known allergies -Apical heart rate -Cardiac rhythm

A: Known allergies Rationale: Since cardiac catheterization involves the injection of a radiopaque dye. It is most important for the nurse to determine if this client has allergies to iodine or shellfish. The other three parameters are also part of the assessment, but are not the priority.

A client is being admitted with nursing home-acquired pneumonia. The unit has four empty beds in semiprivate rooms. The room that would be most suitable for this client is the one with which other client? -60-year-old client admitted for investigation of transient ischemic attacks. -45-year-old client with abdominal hysterectomy. -24-year-old client with non-Hodgkin's lymphoma. -55-year-old client with alcoholic cirrhosis.

A: 60-year-old client admitted for investigation of transient ischemic attacks. Rationale: The client with a possible transient ischemic attack is the only client who has not had surgery and is not immunocompromised. The client with a recent surgery and incision should not be exposed to a client with infection. Clients with cancer or alcoholic cirrhosis are very susceptible to infection, and it would not be safe to expose them to a client with a respiratory infection.

In an outpatient addiction group, a recovering client said that before her treatment, her husband drank on social occasions. "Now he drinks at home, from the time he comes home from work and drinks until he goes to bed. He says that he doesn't like me anymore and that I expect him to do more work on the house and yard. I used to ignore that stuff. I don't know what to do." In which order of priority from first to last would the nurse make the comments? All options must be used. 1 "I hear how confused and frustrated you are." 2 "It can happen that as one person sobers up, the spouse deteriorates." 3 "What have you tried to do about your husband's behaviors?" 4 "What do you think you could do to have your husband come in for an evaluation?"

A: -"I hear how confused and frustrated you are." -"It can happen that as one person sobers up, the spouse deteriorates." -"What have you tried to do about your husband's behaviors?" -"What do you think you could do to have your husband come in for an evaluation?" Rationale: The client's feelings and concerns need to be validated so she will open up more. She also should know that the changes in her husband are not unusual. It helps to know the client has tried with her husband to determine if they are appropriate or not. Then there can be a discussion about getting help for her husband so that her efforts to stay sober are not compromised.

A staff nurse receives a phone call and is told there is a bomb in a client's room. What is the nurse's priority action? -Put the call on hold and find the charge nurse. -Transfer the call to security. -Ask the caller for details about the bomb placement. -Signal to staff to close the client's doors.

A: Ask the caller for details about the bomb placement. Rationale: With imminent danger, it is important to determine as much information as possible, as quickly as possible. Transferring the call, or placing the caller on hold could result in a disconnection and loss of information. Clients may need to be evacuated.

A client is informed by his healthcare provider that a tumor has been found. When the nurse sees the client later, the client states that no one knows what is wrong with him. The nurse determines that the client is experiencing which of the following? -Has a hearing deficit -Could be in denial -Needs teaching reinforced -May not understand medical terminology

A: Could be in denial Rationale: The natural response to a new diagnosis is denial. The question does not suggest any of the other options.

A client is admitted with bacterial meningitis. Which hospital room is the best choice for this client? -a private room down the hall from the nurses' station -an isolation room three doors from the nurses' station -a semiprivate room with a client who has viral meningitis -a two-bed room with a client who previously had bacterial meningitis

A: an isolation room three doors from the nurses' station Rationale: A client with bacterial meningitis should be kept in isolation for at least 24 hours after admission and, during the initial acute phase, should be as close to the nurses' station as possible to allow maximal observation. Placing the client in a room with a client who has viral meningitis may cause harm to both clients because the organisms causing viral and bacterial meningitis differ; either client may contract the other's disease. Immunity to bacterial meningitis can't be acquired; therefore, a client who previously had bacterial meningitis shouldn't be put at risk by rooming with a client who has just been diagnosed with this disease.

A partner of a client diagnosed with Karposi's Sarcoma has refused antiretroviral therapy. The partner confides in the nurse that the client "has just given up. I know with medication my partner will get better and we can go back to the life we once had." The nurse identifies that the partner is experiencing which stage of grieving? -denial stage -anger stage -bargaining stage -depression stage

A: denial stage Rationale: Denial, the avoidance of death's inevitability, is the first step of the grieving process. Anger, the most intense grief reaction, arises when people realize that a family member will die or has died. Bargaining occurs when family members attempt to stall or manipulate the outcome or death. Depression is a response to loss expressed as profound sadness or deep suffering.

In which areas of the United States and Canada is the incidence of tuberculosis highest? -rural farming areas -inner-city areas -areas where clean water standards are low -suburban areas with significant industrial pollution

A: inner-city areas Rationale: Statistics show that of the four geographic areas described, most cases of tuberculosis are found in inner-core residential areas of large cities, where health and sanitation standards tend to be low. Substandard housing, poverty, and crowded living conditions also generally characterize these city areas and contribute to the spread of the disease. Farming areas have a low incidence of tuberculosis. Variations in water standards and industrial pollution are not correlated to tuberculosis incidence.

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

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

A local chemical plant has had an environmental leak requiring the mass evacuation of its employees and neighbors in the surrounding area. The emergency room nurse is in the triage area when the first client is brought to the hospital. What should the nurse do first? -Cut off the client's clothing and dispose of it in hazardous waste containers. -Place the fully clothed client in a shower for decontamination. -Determine what decontamination measures took place in the field before approaching the client. -Discharge or admit all current clients in the emergency department.

A: Determine what decontamination measures took place in the field before approaching the client. Rationale: During a disaster the nurse's priority is personal safety. Determining what decontamination measures have already taken place will inform the nurse of necessary precautions. The nurse should not cut off the clothing or place the client in the shower until an assessment of the hazardous material has been completed. Containing the exposed clients in one area, free from other clients, is important, but the safety of the healthcare workers is the priority.

A client is remanded by the courts for psychiatric treatment. The police record, which dates to the client's early teenage years, includes delinquency, running away, auto theft, and vandalism. The client dropped out of school at age 16 and has been living alone then. This history suggests maladaptive coping, which is associated with: -antisocial personality disorder. -borderline personality disorder. -obsessive-compulsive personality disorder. -narcissistic personality disorder.

A: antisocial personality disorder. Rationale: This client's history of delinquency, running away from home, vandalism, and dropping out of school is characteristic of antisocial personality disorder. This maladaptive coping pattern is manifested by a disregard for societal norms of behavior and an inability to relate meaningfully to others. In borderline personality disorder, the client exhibits mood instability, poor self-image, identity disturbance, and labile affect. Obsessive-compulsive disorder is characterized by a preoccupation with impulses and thoughts that the client realizes are senseless but can't control. Narcissistic personality disorder is characterized by a pattern of self-involvement, grandiosity, and demand for constant attention.

The nurse is assessing the client (see photo) who has recently returned from a 2-month mission in Africa. What type of respiratory protection is appropriate for the staff? -N95 particulate respirator -double-layered surgical mask -surgical mask with eye shield -no respiratory protection needed

A: N95 particulate respirator Rationale: Any type of blistering lesion, such as smallpox, requires extreme care to prevent exposure. Transmission-based precautions for smallpox includes airborne, droplet, and contact precautions. The N95 mask filters at least 95% of airborne particles. To prevent exposure through the respiratory tract, the N95 mask must be fitted and worn properly.

The nurse is preparing a community education program about preventing hepatitis B infection. Which information should be incorporated into the teaching plan? -Hepatitis B is relatively uncommon among college students. -Frequent ingestion of alcohol can predispose an individual to development of hepatitis B. -Good personal hygiene habits are most effective at preventing the spread of hepatitis B. -The use of a condom is advised for sexual intercourse.

A: The use of a condom is advised for sexual intercourse. Rationale: Hepatitis B is spread through exposure to blood or blood products and through high-risk sexual activity. Hepatitis B is considered to be a sexually transmitted disease. High-risk sexual activities include sex with multiple partners, unprotected sex with an infected individual, male homosexual activity, and sexual activity with IV drug users. College students are at high risk for development of hepatitis B and are encouraged to be immunized. Alcohol intake by itself does not predispose an individual to hepatitis B, but it can lead to high-risk behaviors such as unprotected sex. Good personal hygiene alone will not prevent the transmission of hepatitis B.

During a bedside shift report, the nurse finds that the client is receiving the wrong I.V. solution. Which action by the nurse is indicated? -Notify the nurse manager. -Change the solution after shift report is complete. -Write up an incident report describing the error. -Report the off-going nurse to the board of nursing.

A: Write up an incident report describing the error. Rationale: After starting the correct solution, the nurse should complete an incident report describing the specific error. The healthcare provider should be notified as well as the nurse manager; however, if the manager is not present and the error corrected, notification may take place after the report is complete. The solution should be changed to the correct fluids immediately upon discovery so that the error is not continued. The staff nurse does not report a routine error to the board of nursing; if there is concern for substance abuse or other issue, the nurse or manager may choose to involve the board.