emerging care management issues
A client diagnosed with bipolar disorder becomes verbally aggressive during group therapy. The client states, "I hate all of you." Which response by the nurse is best?
You are frightening people. We will walk down the hall to release some energy." Explanation: This response indicates that the behavior is unacceptable, and that the client deserves help. The other responses are nontherapeutic and accusatory.
Which questions have been added to nursing admission assessment to screen for the Ebola virus? Select all that apply.
Correct response: Are you a resident of or have you traveled within the last 21 days to a country where an Ebola outbreak is occurring? Have you been exposed to someone who is suspected or known to have Ebola? Explanation: Asking if the client has Ebola is not part of the screening program. Ebola cannot be prevented by immunizations.
Two weeks ago, a client was prescribed a ten-day course of amoxicillin for a streptococcal infection. The client tells the nurse that symptoms disappeared after 5 days and that the client stopped taking the medication at that time. What is the nurse's best action?
Correct response: Assess the client, and teach about the phenomenon of antibiotic resistance. Explanation: Failing to complete a course of antibiotics contributes to antibiotic resistance. It is important for clients to adhere to treatment, but explaining the rationale for this is most helpful. The client should not restart the antibiotics, and there is no obvious need for a throat culture.
A nurse is reviewing the medication administration record and is getting ready to administer the flu vaccine. Prior to administering the vaccine, the client's spouse asks about getting the vaccine. Which locations will administer the flu vaccine to a client who does not have a primary care provider? Select all that apply.
Correct response: health department pharmacy urgent care clinic Explanation: Flu vaccines are offered in many locations, including doctor's offices, clinics, health departments, pharmacies, and college health centers, as well as by many employers, and even in some schools. Vaccines would not typically be available in a fitness center.
A client in an extremely agitated state is admitted to the psychiatric unit for an opioid overdose. What are important nursing considerations regarding visitors as they relate to the client's care? Select all that apply.
Identify the legal next of kin, and acknowledge immediate family members. Identify friends who may have additional details about this overdose. Recognize that visitors may smuggle contraband opioids into the hospital. Acknowledge that visiting restrictions may need to be put into place. Explanation: The nurse will need to identify who the next of kin is as well as family members who have a legal right to visit the client. Clients who abuse drugs often have strained relationships with family members. There may also be a live-in or common law partner of either gender. Friends may hold valuable information about the specific overdose episode or the client's drug use in general. Visitors coming into the hospital may intentionally bring contraband for the client's use. After these issues have been assessed, it may be necessary to place visiting restrictions in place for the safety of the client and others in the hospital environment. The nurse does not need to have a security guard placed at the doorway unless it is a criminal case.
A new nurse is asked to present a case study during interdisciplinary rounds on a client who has compartment syndrome from a leg injury. The new nurse is uncomfortable with public speaking. Which action(s) by the new nurse is appropriate? Select all that apply.
Research the condition, and present what was learned. Review the client's chart to obtain assessment findings and treatment. Explanation: This is an opportunity for new learning about a complication that pertains to the client and an important safety consideration when assessing and performing care measures. Presenting this case would also provide a professional growth opportunity. As a new professional on a unit, it is important to go beyond one's normal comfort zone. Attending rounds will be a learning experience, but not a challenging growth experience. Deferring to a more experienced nurse or approaching the nurse manager demonstrates avoidance of growth opportunities and failure to confront insecurities.
The nurse on a gerontology unit will be admitting several new clients to the unit over the next few hours. There are two shared rooms and one single-client room currently vacant on the unit. Which client should be placed in the single-client room?
a client who has developed hypokalemia due to Clostridium difficile-related diarrhea Explanation: For reasons of infection control, a client with Clostridium difficile-related diarrhea must be housed in a single room. This infection control measure would supersede the need to accommodate visitors. It is ideal for a client who is agitated to be in a single-client room, but the necessity of infection control would override this factor.
A client, diagnosed with active tuberculosis (TB), asks the nurse if they will be admitt
prevent the spread of the disease. Explanation: A client with active TB is highly contagious until three consecutive sputum cultures are negative. This client should be put on respiratory isolation in a hospital setting.
