LEADERSHIP AND MENTAL HEALTH MIDTERM BONUS

A nurse is caring for a client who has a depressive disorder. The client states, "I just can't feel any happiness or joy in life." Which of the following terms should the nurse use when documenting this finding? Anhedonia Anergia Anosognosia Akathisia

Anhedonia Anhedonia refers to the client's inability to experience pleasure or joy.

A nurse is leading a family therapy session for a mother, father, and two adolescent siblings. Which of the following statements should the nurse recognize as an example of effective communication among family members? "If you keep saying that, I will tell everyone what you did last night." "She is always bossing me around. Should she do that?" "Can you tell me the reason you get upset each time I go to the mall?" "Please do not raise your voice at the children. I am the one who left dishes in the sink."

"Can you tell me the reason you get upset each time I go to the mall?" This is an example of effective or healthy communication. Healthy communication expresses clear, understandable messages between family members. Each family member is encouraged to express his or her own feelings and thoughts. The family member is asking the member who is perceived to be upset to express feelings openly. The communication is clear, understandable, and direct. This promotes an open exchange of feelings and thoughts.

A nurse manager on a mental health unit is discussing involuntary admissions during a staff meeting. Which of the following statements should the manager include in the discussion? "Clients should be given medications even if they refuse them." "The laws regarding restraints are different for clients who are admitted involuntarily." "Clients who are admitted involuntarily can be hospitalized for as long as the provider deems necessary." "Clients who are involuntarily admitted have the right to informed consent."

"Clients who are involuntarily admitted have the right to informed consent." Clients who are admitted involuntarily retain the right to informed consent.

A nurse is assisting a newly licensed nurse with delegating tasks to an assistive personnel on the unit. Which of the following statements by the nurse explains the purpose of delegation? "Delegation provides appropriate resources for the client." "Delegation permits a designated individual to meet a goal on your behalf." "Delegation promotes discharge teaching activities for clients." "Delegation decreases health care costs."

"Delegation permits a designated individual to meet a goal on your behalf." Delegation is defined as directing the performance of others to accomplish goals of the nurse and the facility.

A nurse is preparing to witness informed consent for a client who is preoperative. The client asks the nurse, "Are there other options besides surgery?" Which of the following responses should the nurse make? "It is time to sign the consent so your treatment can begin." "I would not have this type of surgery if I were you." "Have you discussed other treatments with your provider?" "I can inform the surgeon you do not want the surgery."

"Have you discussed other treatments with your provider?" The nurse should seek clarification to determine what the client may or may not know about alternatives to the surgical procedure. The nurse should notify the provider about the need to discuss alternatives to surgery if necessary. Informed consent requires that the client is aware of the limitations and alternatives to the procedure.

A nurse is caring for a client who has named a person to serve as his health care proxy. The client states he needs clarification about this type of advance directives. Which of the following statements by the client indicates a need for clarification? "I can change who I designate as my health care proxy at any time." "If I become incapacitated, end-of-life choices will be made by my proxy." "I have to choose a family member as my health proxy." "The health care proxy does not go into effect until I am incapable of making decisions."

"I have to choose a family member as my health proxy." The client should choose someone he trusts and knows about his wishes for day-to-day and end-of-life care. It can be a family member, but it does not have to be a family member.

A nurse is teaching a client who has a new prescription for chlorpromazine. Which of the following client statements indicates an understanding of the teaching? "This medication will help me stop smoking." "I may have a dry mouth while taking this medication." "I should expect flu-like symptoms while taking this medication." "This medication may cause me to urinate frequently."

"I may have a dry mouth while taking this medication." Chlorpromazine causes anticholinergic effects, such as dry mouth and constipation.

A nurse in an acute mental health facility is caring for a client who has major depressive disorder. Since her admission 3 days ago, she has not put on clean clothes, washed her hair, or participated in any of the unit activities. On this day, the nurse observes that she is wearing clean clothes and has combed her hair. Which of the following responses should the nurse make? "Oh, I'm so pleased that you finally put on clean clothes." "Why did your wear clean clothes and comb your hair today?" "Your mood must be lifting because you have on clean clothes and have combed your hair." "I see that you have on clean clothes and have combed your hair."

"I see that you have on clean clothes and have combed your hair." This comment provides recognition of the client's behavior and efforts at self care without making a value judgment or offering approval. This is a therapeutic communication technique.

A nurse on a crisis hotline is speaking to a client who says, "I just took an entire bottle of amitriptyline." Which of the following responses should the nurse make? "I'm glad you called, and I want to send an ambulance to help you." "You must have been feeling pretty depressed to do that." "Do you know how many pills were in the bottle?" "Were you trying to kill yourself by taking an overdose?"

"I'm glad you called, and I want to send an ambulance to help you." Amitriptyline, a tricyclic antidepressant, is used to treat depression. This therapeutic statement shows the nurse's concern for the client's safety and responds to the client's priority need. Maslow's hierarchy of needs states that the client's physical and safety needs come first. Therefore, the client needs to be evaluated immediately.

A nurse is caring for a client whose partner is requesting to bring the client food from home that is not allowed in the client's dietary plan. Which of the following responses should the nurse make? "Why would you want to put your partner's health at further risk?" "Everyone likes food from home, but it can delay your partner's recovery." "You will need to discuss your concerns about your partner's diet with the provider." "Let's try to find ways to incorporate your partner's favorite food into her diet plan."

"Let's try to find ways to incorporate your partner's favorite food into her diet plan." This response illustrates the therapeutic communication technique of formulating a plan of action. It demonstrates the nurse's willingness to work with the partner to modify the proposal so that it meets the client's dietary needs at this time.

An assistive personnel (AP) comes to work with a new set of artificial nails. The nurse takes the AP to a private location to discuss the issue. Which of the following statements by the nurse is appropriate? "There is a higher risk of infection for our clients associated with artificial nails." "You should know that artificial nails have a very unprofessional appearance." "I want you to review the facility's policy on personal attire before you begin the shift." "Why would you wear artificial nails to work when you know it's against the rules?"

"There is a higher risk of infection for our clients associated with artificial nails." Short, natural nails are less likely to harbor pathogens that can be harmful to clients. The CDC recommends health care workers avoid wearing artificial nails when caring for clients who are at risk for infection. Additionally, guidelines from the World Health Organization prohibit artificial nails for caregivers in every setting.

A nurse is caring for a client admitted to a mental health facility who asks, "Can I refuse the electroconvulsive therapy (ECT) treatment scheduled for tomorrow?" Which of the following should be the nurse's response? "You have given signed consent for the treatments after they were explained to you." "You will feel better after the course of treatments." "You can refuse them, but the provider believes they are necessary." "You have the right to refuse even though the consent form has been signed."

"You have the right to refuse even though the consent form has been signed." Informed consent is a communication between provider and client regarding the risks and benefits of treatment. The client authorizes the treatment with a witnessed signature to undergo the medical intervention. The client has the right to refuse or delay treatment, even though the informed consent has been signed.

A nurse is caring for a client who is hospitalized and says to the nurse, "My partner called and told me my boss hired someone to take my place." Which of the following responses should the nurse make? "You should call your boss and ask if you can have your job back." "I don't understand why your partner would upset you with news like that." "There really isn't much you can do about that until you are discharged." "You must feel very concerned and disappointed by that information."

"You must feel very concerned and disappointed by that information." This is a therapeutic response and an open-ended empathetic statement that encourages the client to talk.

A nurse is assisting a client who has schizophrenia prepare a relapse plan. Which of the following statements should the nurse make? "You should be aware that excessive sleeping is an early sign of relapse." "Relapse is an indication that you are not taking your medications properly." "You should keep your provider's and therapist's number with you." "Taking an additional dose of medication is appropriate as soon as signs of relapse appear."

"You should keep your provider's and therapist's number with you." The client should have a written plan, including important numbers, available at all times in case relapse occurs.

A nurse is observing a newly licensed nurse as she interacts with a client regarding his concerns about his relationship with his partner. Which of the following statements by the newly licensed nurse requires intervention by the nurse? "Tell me about the concerns that you have regarding your relationship." "You should try to see your partner's point of view before your own." "We could develop a plan for how to talk about this with your partner." "Relationship difficulties are stressful and require effort to resolve."

"You should try to see your partner's point of view before your own." This statement gives advice, which is nontherapeutic.

A nurse on an obstetrics-gynecology unit is planning care for four clients after receiving change of shift report. Which of the following clients should the nurse assess first? A client who is a 1 day postpartum after a late term miscarriage A client who had a bilateral tubal ligation 12 hr previously A client who is 4 days postpartum and has mastitis A client admitted 1 hr ago for an ectopic pregnancy

A client admitted 1 hr ago for an ectopic pregnancy A client who has an ectopic pregnancy is unstable. The client is at risk for rupture of the fallopian tube, hemorrhage, and shock. Nursing care requires frequent monitoring every 15 min, IV access for fluid resuscitation. The client may also require blood transfusions, oxygen, and pain management. Therefore this client is the highest priority.

A nurse is assigned a group of clients at the start of the shift. Which of the following clients should the nurse plan to care for first? A client who needs assistance with a bath A client requesting a referral for home health services A client asking about his PCA pump that contains morphine A client who has questions about his new prescription

A client asking about his PCA pump that contains morphine Clients who are administered morphine are at risk for respiratory distress. When using the urgent vs. nonurgent approach to client care, this is the client the nurse should care for first.

A nurse is caring for several clients. For which of the following situations should the nurse complete an incident report? The nurse identifies a broken piece of equipment. A staff member does not show up to work her assigned shift. A client discovers that his dentures are missing. The nurse has a disagreement with the nursing supervisor about inadequate staffing.

A client discovers that his dentures are missing. This situation represents a variation from the normal standard of care. A change in the client's plan of care may be necessary if the client has difficulty eating or speaking without the dentures. In addition, the facility may be liable for replacing the missing dentures.

A nurse is assessing four clients on a medical-surgical unit. Which of the following clients should the nurse care for first? A client who has diarrhea and requests clear liquids for breakfast A client who has a cast on the left leg and reports numbness and paresthesia A client who has type 1 diabetes mellitus and has a fasting blood glucose level of 150 A client who has pneumonia and has an axillary temperature of 38° C (101° F)

A client who has a cast on the left leg and reports numbness and paresthesia The client who has a cast is at risk for acute compartment syndrome (ACS). Numbness and paresthesia are manifestations of ACS; therefore, when using the airway, breathing, circulation (ABC) approach to client care, the nurse should care for this client first.

An RN from the maternal-newborn unit is being floated to a medical-surgical unit. Which of the following clients should the charge nurse on the medical-surgical unit plan to assign to the RN? A client who has terminal end-stage renal disease A client who has acute pancreatitis A client who is one-day postoperative following a total abdominal hysterectomy A client who had a stroke and is to be admitted

A client who is one-day postoperative following a total abdominal hysterectomy The nurse who floats to another unit must have the skills to provide safe care to clients. This client is stable. This is an appropriate assignment for the RN.

A nurse is triaging clients in the emergency department. Which of the following clients should the nurse ask the provider to care for first? A toddler who has asthma and has a pulse oximetry reading of 95% while receiving oxygen at 2 L/min A toddler who has otitis media, a temperature of 39.2° C (102.6° F), and purulent ear discharge A school-age child who has acute epiglottitis, is drooling, and has an absence of spontaneous cough An adolescent who has sickle cell disease, reports pain as 7 on a scale of 0 to 10, and requests pain medication

A school-age child who has acute epiglottitis, is drooling, and has an absence of spontaneous cough A client who has acute epiglottitis, is drooling, and has an absence of spontaneous cough is unstable and requires immediate medical attention; therefore, this client is the priority and the nurse should have the provider care for this client first.

A nurse in a mental health clinic is assessing a client who was brought in by her adult daughter stating that her mother has not been able to leave her home for weeks because she is afraid to be outdoors alone. The nurse should anticipate planning care for managing which of the following phobias? Xenophobia Acrophobia Mysophobia Agoraphobia

Agoraphobia Agoraphobia is an irrational fear about being in places or circumstances where the client would not have help in the event of panic or other forms of anxiety. Fear of being alone outdoors is a common example.

A nurse is caring for an adolescent female who has an eating disorder. The client is 162.6 cm (64 in) tall and weighs 38.56 kg (85 lb). Upon assessment, which of the following manifestations should the nurse expect? (Select all that apply.) Amenorrhea Verbalized desire to gain weight Altered body image Hyperactivity Bradycardia

Amenorrhea is correct. A client who has anorexia nervosa and has had significant weight loss will commonly experience amenorrhea, or cessation of menses. Altered body image is correct. A client who has anorexia nervosa will commonly view her body as overweight no matter how much weight is lost. Hyperactivity is correct. A client who has anorexia nervosa will commonly engage in excessive exercising to prevent weight gain. Bradycardia is correct. A client who has anorexia nervosa can experience cardiac abnormalities, such as bradycardia and hypotension.

A nurse on a pediatric unit is reviewing her client assignment following the shift report. Which of the following clients should the nurse plan to assess first? A school-age child who has diabetes mellitus and requires blood glucose monitoring An infant who has pertussis and is receiving oxygen via nasal cannula An adolescent who was admitted to the unit in sickle cell crisis and is ready for discharge instructions A toddler who has both arms in casts and needs to be fed his breakfast

An infant who has pertussis and is receiving oxygen via nasal cannula Using the airway, breathing, circulation (ABC) approach to prioritizing client care, this infant should be assessed first because the infant has a compromised airway and requires oxygen.

A nurse on a surgical unit is caring for a group of clients. Which of the following is the priority action of the nurse? Taking a telephone prescription about a client who is to be transferred from PACU Assessing a client who experiences unilateral calf pain when ambulating Reinforcing a client's dressing for the surgical site of an above-the-knee amputation Reassuring the partner of a client who sustained a closed head injury

Assessing a client who experiences unilateral calf pain when ambulating When using the urgent vs nonurgent approach to client care, the nurse should determine that the priority action is assessing a client who has manifestations of a deep vein thrombosis, which can lead to pulmonary embolus. The nurse should assess this client and report the findings immediately to the provider.

A charge nurse is delegating tasks to nursing personnel on a 10-bed medical-surgical nursing unit. Which of the following assignments is an example of overdelegation? Assigning two assistive personnel (AP) to ambulate all clients Assigning a new graduate nurse to perform a wet-to-dry dressing change Assigning the most efficient AP to perform glucometer monitoring for each client Assigning the most competent RN to perform a central line dressing change

Assigning the most efficient AP to perform glucometer monitoring for each client Asking the most efficient AP to perform glucometer testing based on her efficiency in performing this task is an example of overdelegation. This can result in the AP becoming overworked and tired, thus decreasing productivity.

A nurse is teaching a class on torts. The nurse should instruct the class that administering an antibiotic medication to a competent client after the client has refused it is an example of which of the following torts? Assault False imprisonment Negligence Battery

Battery Battery is physical contact without the client's consent. Administering a medication against a client's wishes is an example of battery.

A nurse in an outpatient clinic is caring for a client who has schizophrenia. Graphic Record 1130: Temperature: 98.4° F (36.9° C) oral Heart rate: 86/min Respiratory rate: 18/min BP: 118/72 mm Hg SpO2: 98% room air Nurses' Notes 1140: Client's parent brought client to clinic after noticing the client was speaking to unseen others and avoids eating food that they do not prepare for themselves. Client states, "people try to poison my food sometimes." Client noted to respond in an unintelligible whisper to unseen others and is repeatedly looking at the corner of room as though watching someone or something. History and Physical 1155: Client is a 28-year-old female who was diagnosed with schizophrenia approximately 10 years ago. They have been hospitalized twice for psychosis and medication management. Otherwise, their treatment plan is managed on an outpatient basis. The client lives with a partner and works at a local retail store. They see their parents 1 to 2 times per week and they are the client's primary support system. Client has no other medical conditions or recent changes in health status. Provider Prescriptions 1330 - Inpatient Admission Prescriptions: Clozapine 12.5 mg PO

Client denies sore throat is correct. The improvement in the client's sore throat indicates that the agranulocytosis is likely improving, decreasing the client's risk for infection. This indicates that the treatment plan is effective. Client states, "I haven't heard any voices in my head since yesterday" is correct. This statement indicates that the client's auditory hallucinations have decreased, which indicates the treatment plan is effective. Client showered and fixed hair without prompting is correct. The client had been experiencing a decrease in energy which affects the ability to perform self-care needs. Performance of ADLs without prompting from the nurse indicates the treatment plan is effective. Client's ANC 2,500/mm3 is correct. This ANC level is within the expected reference range of 2,500 to 8,000/mm3. This result indicates the treatment plan is effective. An ANC level between 500 and 999/mm3, is considered moderate neutropenia, which is an indication that client could be immunocompromised.

A nurse is planning a community diabetes mellitus management program. Which of the following goals should the nurse include for the program? Proper foot care will be demonstrated to clients during the program. Clients will have a decreased incidence of foot amputations. A facility will be reserved for the program. Handouts and teaching materials will be distributed at the program.

Clients will have a decreased incidence of foot amputations. A goal is the desired result toward which effort is directed. A reduced incidence of foot amputations is an appropriate, measurable, and realistic goal for a community diabetes management program.

A nurse in the emergency department is caring for a client who was sexually assaulted. Which of the following resources will provide the most effective support immediately following the incident? Psychologist Close friend Social worker Chaplain

Close friend Sexual assault survivors who confide in a family member or friend immediately after the incident are more likely to develop fewer somatic manifestations of stress.

A nurse is caring for a client who is preoperative. The nurse signs as a witness on the client's consent form. The nurse's signature on the consent form indicates which of the following? Determines the client does not have a mental illness Confirms the client appears competent to provide consent Asserts the nurse has explained the risks and benefits of the procedure Records that the client's spouse agrees the procedure is necessary

Confirms the client appears competent to provide consent By signing as a witness on a procedural consent form, the nurse is confirming the client was the one who signed the consent form and that he seems to be competent to give consent.

A home-health nurse is assessing a client who has obsessive-compulsive disorder (OCD) and finds that the client demonstrates constant repetitive cleaning. The nurse knows that this behavior is an attempt to accomplish which of the following? Decrease anxiety. Prevent aggressive and impulsive behaviors. Manipulate others. Decrease the time available for interaction with people.

Decrease anxiety. Repetitive, ritualistic behavior is an attempt by a client who has OCD to decrease anxiety.

A nurse manager is preparing an inservice program for the nurses on the unit about the use of a new infusion pump. Which of the following teaching strategies is the most effective way to ensure that the staff can use the device correctly? Provide a written procedure for the use of the device for the staff to review. Demonstrate using the device and observe the staff returning the demonstration. Remind the staff to review the procedure manual prior to using the new pump. Identify the differences and new features of the device in a written brochure.

Demonstrate using the device and observe the staff returning the demonstration. The most effective strategy to ensure the staff nurses can perform a psychomotor skill, such as using an infusion pump, is to show them how to use the device and provide the opportunity for a return demonstration.

A nurse is performing an admission assessment for a client who is receiving treatment following a situational crisis. Which of the following assessments by the nurse is the highest priority? Determining if the client has psychotic thinking Asking the client to identify the cause of the crisis Identifying the client's coping skills Identifying the client's support systems

Determining if the client has psychotic thinking Clients experiencing a situational crisis are at greatest risk for injury to themselves or others; therefore, determining if psychotic thinking is present is the highest priority.

A nurse is preparing to assist with electroconvulsive therapy (ECT). Which of the following pieces of equipment should the nurse set up in the room prior to the treatment? (Select all that apply.) Electroencephalogram (EEG) monitor Blood pressure monitor Ophthalmoscope Cardiac monitor Portable x-ray machine

Electroencephalogram (EEG) monitor is correct. During ECT, the client is monitored with an EEG to track brain wave patterns. Blood pressure monitor is correct. During ECT, the client's blood pressure is monitored to identify changes that can indicate cardiac stress. Cardiac monitor is correct During ECT, the client is monitored with continuous telemetry to identify arrhythmias or other changes in the tracing.

A nurse is caring for a client who is scheduled to have surgery. In preparing the client for surgery, which of the following actions is considered outside the nurse's responsibilities? Assessing the current health status of the client Explaining the operative procedure, risks, and benefits Reviewing preoperative laboratory test results Ensuring that a signed surgical consent form was completed

Explaining the operative procedure, risks, and benefits Explaining the procedure and any risks that may be associated with it is the responsibility of the person performing the procedure. This is not a nursing responsibility.

A nurse is preparing to administer amantadine 150 mg PO every 12 hr. Available is amantadine 50 mg/5 mL syrup. How many mL should the nurse administer per dose? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.) _______mL

Follow these steps for the Ratio and Proportion method of calculation: Step 1: What is the unit of measurement the nurse should calculate? mL Step 2: What is the dose the nurse should administer? Dose to administer = Desired 150 mg Step 3: What is the dose available? Dose available = Have 50 mg Step 4: Should the nurse convert the units of measurement? No Step 5: What is the quantity of the dose available? 5 mL Step 6: Set up an equation and solve for X. HaveDesired = QuantityX 50 mg150 mg = 5 mLX mL X mL = 15 mL

A nurse is preparing to administer diphenhydramine 50 mg PO every 6 hr to a client who has acute dystonia. Available is diphenhydramine 25 mg tablets. How many tablets should the nurse administer per dose? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.) ________tablet(s)

Follow these steps for the Ratio and Proportion method of calculation: Step 1: What is the unit of measurement the nurse should calculate? tablet(s) Step 2: What is the dose the nurse should administer? Dose to administer = Desired 50 mg Step 3: What is the dose available? Dose available = Have 25 mg Step 4: Should the nurse convert the units of measurement? No Step 5: What is the quantity of the dose available? 1 tablet Step 6: Set up an equation and solve for X. HaveDesired = QuantityX 25 mg50 mg = 1 tabletX tablet(s) X tablet(s) = 2 tablets

A charge nurse is working with an assistive personnel (AP) who provides excellent care to clients and is an effective team member. Which of the following actions should the nurse take first to recognize the AP's contributions to client care? Give positive feedback directly to the AP. Tell other nurses what an effective team member the AP is. Nominate the AP for the Employee of the Month award. Detail the AP's contributions to the nurse manager.

Give positive feedback directly to the AP. Positive reinforcement is one of the most effective ways to recognize an employee's ability and to motivate the employee.

A client commits suicide in an acute mental health facility. Which of the following is the priority intervention for staff following this incident? Provide professional counseling for staff members. Change policies for staff observation of clients who are suicidal. Identify cues in the client's behavior that might have warned them that he was contemplating suicide. Give the family an opportunity to talk about their feelings.

Identify cues in the client's behavior that might have warned them that he was contemplating suicide. Identifying cues in the client's behavior is the priority intervention when taking the nursing process approach to client care. Assessment is the first step in dealing with a situation.

A nurse is caring for a newly admitted client who has obsessive-compulsive disorder (OCD). Which of the following actions should the nurse take first? Discuss alternative coping strategies with the client. Identify precipitating factors for ritualistic behaviors. Instruct the client on relaxation techniques for use when anxiety increases. Provide a structured activity schedule for the client.

Identify precipitating factors for ritualistic behaviors. This is the priority intervention when taking the nursing process approach to client care.

A nurse is caring for a 48-year-old client who is grieving following the death of her husband seven months ago. The client reports that she has lost 30 lb, and is having difficulty sleeping. Which of the following factors indicate the client is experiencing maladaptive grieving? The client is 48 years old. The client's husband died seven months ago. The client has lost 30 lb. The client is having difficulty sleeping.

The client's husband died seven months ago. One of the defining factors of maladaptive grieving is grief that lasts 6 months or longer after the loss.

A nurse is participating in a disaster simulation in which a toxic substance is released into a crowded stadium. Multiple clients are transported to the facility. Which of the following activities would be the lowest priority for the nurse? Preventing cross-contamination of clients Performing concise client assessment Transferring a client to the discharge location Maintaining a client tracking system

Transferring a client to the discharge location Nursing care in a disaster setting focuses on essential care. The nurse should recognize nonskilled interventions, such as transferring a client to the discharge location, can be performed by nonmedical personnel.

A nurse is assessing a client who has posttraumatic stress disorder (PTSD) following a sexual assault. Which of the following is an expected finding? Sleeping 12 hr or more each day. Increasing sense of attachment to others. Constant need to talk about the event. Increasing feelings of anger.

Increasing feelings of anger. Increasing anger and irritability are findings associated with PTSD.

A nurse in the emergency department is caring for a client who has a compression fracture of a spinal vertebra. During transport to the facility, the client was medicated with intravenous morphine. On arrival, the neurosurgeon determined urgent surgical intervention is indicated for the fracture. Staff members have been unable to reach the client's family. Which of the following actions should the nurse anticipate the neurosurgeon taking? Invoking implied consent Delaying the surgery until a member of the client's family is reached Asking the client to sign the surgical consent form Prescribing naloxone to reverse the effects of the morphine

Invoking implied consent The client is unable to sign the consent form because he is sedated from the morphine. The neurosurgeon has the legal right to invoke implied consent and proceed with the surgery if it is determined an emergency and surgery is in the client's best interest. The neurosurgeon should document the specifics of the situation in the client's medical record.

A nurse is caring for a group of clients. The nurse demonstrates adherence to the ethical principle of fidelity by doing which of the following? Keeping an appointment with a client Allowing a new mother to hold her stillborn infant Confirming that a client going for surgery has signed a consent form Refusing to disclose information about a client to the media

Keeping an appointment with a client Fidelity is the duty to keep one's promises or word. Keeping an appointment the nurse has made with the client is an example of fidelity.

A nurse is caring for a client who lost all his possessions in a house fire and states, "I have no idea what I am going to do. I cannot think right now." Which of the following actions should the nurse take? Identify other housing options and sources of transportation. Notify the facility chaplain to request scheduling an appointment. Confirm that everything will be all right because belongings can be replaced. Maintain eye contact with client and summarize the client's feelings.

Maintain eye contact with client and summarize the client's feelings. This demonstrates therapeutic communication. During the initial interview, it is important for the nurse to provide an atmosphere of support and safety. If a person believes that someone is genuinely concerned, then he may believe that help is available. Maintaining eye contact demonstrates support, empathy, and advocacy.

A nurse finds that a client did not receive a scheduled dose of furosemide (Lasix). Which of the following should the nurse include in the incident/variance report? (Select all that apply.) The date of the incident The name of the provider who prescribed the medication The potential adverse effects of the medication The time the client was to receive the medication The client's vital signs

The date of the incident is correct. When a nurse discovers a medication error, it is her legal responsibility to complete an incident report. A health care agency can use incident reports to monitor incidents and accidents in order to prevent future occurrences. The report should only include factual information about the incident such as the date. The time the client was to receive the medication is correct. The nurse should include the time the client was to receive the medication because this pertains directly to the incident of the omitted medication. The client's vital signs is correct. The nurse should assess the client as soon as she discovers the error and should include the assessment data in the report.

A nurse notes a provider frequently arrives to the unit with bloodshot eyes and smells like alcohol after lunch. Which of the following actions should the nurse take? Counsel the provider to determine the cause of the substance abuse. Encourage clients to change to a different provider. Inform the state medical board for an immediate investigation. Notify the nursing supervisor of the concerns.

Notify the nursing supervisor of the concerns. The nurse should notify hospital or nursing management of the concerns, and then ensure client safety. It is the responsibility of management to conduct an investigation. Client safety is the responsibility of the nurse.

A nurse and an experienced licensed practical nurse (LPN) are caring for a group of clients. Which of the following tasks should the nurse delegate to the LPN? (Select all that apply.) Provide discharge instructions to a confused client's spouse. Obtain vital signs from a client who is 6 hr postoperative. Administer a tap-water enema to a client who is preoperative. Initiate a plan of care for a client who is postoperative from an appendectomy. Catheterize a client who has not voided in 8 hr.

Obtaining vital signs from a client who is 6 hr postoperative is correct. Obtaining is a task that is appropriate to the education and skills of an LPN. Administering a tap-water enema to a client who is preoperative is correct. Administering a tap-water enema is a task that is appropriate to the education and skills of an LPN. Catheterizing a client who has not voided in 8 hr is correct. Urinary catheterization is a task that is appropriate to the education and skills of an LPN.

A nurse in a community clinic facility notices a change in a client's behavior. Which of the following manifestations is the priority for the nurse to report? Onset of command hallucinations Development of magical thinking Development of a diminished affect Onset of anergia

Onset of command hallucinations Command hallucinations occur when a client who has schizophrenia believes he is told to take some sort of action. These actions can include hurting another person or the client. The greatest risk to this client is injury from the client acting on a command hallucination in order to harm himself or others. Therefore, the priority manifestation to report is the onset of command hallucinations.

A charge nurse is observing a nurse insert an indwelling urinary catheter into a female client. For which of the following actions by the nurse should the charge nurse intervene? The nurse separates the client's labia with her dominant hand. The nurse coats the indwelling urinary catheter with lubricant. The nurse provides perineal care prior to inserting the urinary catheter. The nurse applies the sterile drape prior to inserting the urinary catheter.

The nurse separates the client's labia with her dominant hand. The nurse should use her non-dominant hand to separate the labia, or to hold the penis in male clients. The dominant hand is the hand that should handle the catheter during insertion and when filling the balloon. If the nurse separated the labia with her dominant hand, it would be more difficult to insert the catheter in a sterile environment and could result in introduction of bacteria into the urinary tract.

A nurse in a long-term care facility is caring for a client who has Alzheimer's disease. Which of the following actions should the nurse include in the plan of care? Post a written schedule of daily activities. Use an overhead loudspeaker to announce events. Provide a consistent daily routine. Allow the client to choose free-time activities.

Provide a consistent daily routine. A consistent daily routine is appropriate for the care of a client who has Alzheimer's disease.

A nurse in an emergency department receives report from an emergency responder who states a client is being transported following exposure to a "dirty bomb". The nurse should prepare to care for a client that has been exposed to which of the following types of agents? Chemical Anthrax Radiologic Sarin

Radiologic A "dirty bomb" combines radiologic agents with an explosive device, resulting in immediate effects of radiation exposure.

A nurse checks with assistive personnel on the unit throughout the shift to determine if they are completing tasks. The nurse is demonstrating which of the following rights of delegation? Right circumstances Right communication Right person Right supervision

Right supervision The nurse is demonstrating the right supervision when she assesses how the tasks are being accomplished and if any improvements are needed.

A nurse who is leading a team of nurse managers is planning to make a major announcement. The nurse should use which of the following nonverbal communication techniques to enhance the importance of the announcement? Sit in front of the group for the meeting and then stand for the announcement. Cross her arms over her chest when beginning the announcement. Stare at the people the announcement will affect the most. Lean gently over the back of a chair sitting to one side of the room when making the announcement.

Sit in front of the group for the meeting and then stand for the announcement. The weight of a message increases when the sender stands.

A nurse is planning a unit orientation for a newly admitted client who has severe depression. Which of the following should be the nurse's approach? Sit with the client and offer simple, direct information. Have the client attend group therapy immediately. Explain the unit policies to the client and answer any questions he might have. Take the client on a tour of the unit and introduce him to all the staff members on duty.

Sit with the client and offer simple, direct information. Severely depressed clients can have problems with concentration and are easily overwhelmed. A nursing approach that focuses on giving simple information slowly and directly is best for the newly admitted client.

An RN is delegating care activities to a licensed practical nurse (LPN). Which of the following is the priority criterion the RN should consider when delegating? Agency policies for the LPN The documented experience level of the LPN The documented skill level of the LPN State Nurse Practice Act for the LPN

State Nurse Practice Act for the LPN According to evidence-based practice, the nurse should first consider the state Nurse Practice Act for the LPN. This act guides agency policies and provides the legal authority for nursing practice, including delegation.

A nurse is caring for a client in the emergency department (ED). Medical History Client has a history of bipolar disorder, cholecystitis, and type 2 diabetes mellitus. Nurses' Notes 1000: Client is brought to the ED by family member who states that the client has not eaten, slept, or taken their medications in at least 2 days. Client's family member states that the client's behavior is typical of manic episodes in the past. 1200: Client is alert and oriented x 2. Client is pacing the exam room and refuses to sit down. Becomes agitated when asked questions. Client appears to be pale, disheveled, and is wearing dirty clothes. Able to obtain vital signs. However, no other physical assessment as the client becomes severely agitated. Vital Signs Temperature 37.3° C (99.1° F) Heart rate 110/min Respiratory rate 24/min Blood pressure 168/89 mm Hg Oxygen saturation 97% on room air Which of the following 3 interventions should the nurse implement? Stay with the client. Place the client in a room close to the nurses' station. Offer the client a caffeinated beverage. Weigh the client daily. Offer the client finger foods.

Stay with the client is correct. The nurse should stay with the client until they are no longer agitated to ensure their safety. Weigh the client daily is correct. The client should be weighed daily to monitor nutritional status. Offer the client finger foods is correct. The client should be provided with frequent, high-calorie meals that are easy to eat "on the go," such as finger foods.

A nurse is caring for a client who falls in his room. After the nurse assesses the client, notifies the client's provider, and completes an incident report, which of the following actions should the nurse take? Make a copy of the incident report for the provider. Submit the incident report to the risk manager. Place the incident report in the client's chart. Document in the chart that an incidence report has been filed.

Submit the incident report to the risk manager. The purpose of an incident report is to provide information to the risk manager who will investigate the incident and work with other members of the health care team to control risks of client injury.

A charge nurse has assigned a group of clients to a licensed practical nurse (LPN). The charge nurse receives reports from her assigned clients about the LPN's lack of care. Which of the following actions should the charge nurse take? Review the LPN's personnel file. Discuss the LPN's behavior with other nurses on the unit. Talk with the clients who have reported the LPN's lack of care. Reassign some of the LPN's client care to assistive personnel.

Talk with the clients who have reported the LPN's lack of care. The charge nurse should investigate the allegations of misconduct to determine if disciplinary action is warranted.

A nurse in a psychiatric unit is admitting a client who attacked a neighbor. The nurse should know that the client can be kept in the hospital after the 72-hr hold is over for which of the following conditions? The client is a danger to herself or others. The client is unwilling to accept that treatment is needed. The client states that she does not like the neighbor. The client states that she plans to move out of the state immediately.

The client is a danger to herself or others. The criteria for involuntary admission includes that the client has a mental disorder that will likely result in serious bodily harm to self or another person, unless the client remains in a psychiatric facility.

A nurse is planning care for a newly admitted client who has major depressive disorder following the loss of a child. Which of the following goals should the nurse identify as the priority? The client makes a contract not to harm herself. The client exhibits expected grieving behaviors. The client identifies positive qualities about herself. The client assumes an active role in her care planning process.

The client makes a contract not to harm herself. A client who has major depressive disorder might be at risk for self-harm. This goal is the priority because it focuses on client safety.

A nurse is caring for a client who has schizophrenia and generalized anxiety disorder. The client has a prescription for alprazolam 0.25 mg PO every 8 hr PRN anxiety. For which of the following client statements should the nurse consider administering alprazolam? The client states, "I see purple bugs crawling on the wall." The client tells the nurse that he is too tired to attend the group meeting. The client tells the nurse he is a government agent. The client states, "My heart is pounding out of my chest."

The client states, "My heart is pounding out of my chest." Alprazolam is a benzodiazepine and is used to treat anxiety. The medication works in the central nervous system to decrease the severity of panic attacks, decrease anxiety and insomnia, and promote relaxation of muscles. Physiological symptoms of anxiety as it reaches the panic level often include tension, impatience, apprehension, increased heart and respiratory rates, confusion, feelings of impending doom, and extreme fright and horror. Expected adverse effects of alprazolam are dizziness, lightheadedness, and drowsiness. The nurse should closely monitor the client and assist the client with ambulation and self-care needs.

An RN is making nursing staff assignments for his team consisting of himself, two licensed practical nurses (LPNs), and an assistive personnel (AP). Which of the following clients should he assume responsibility for? The client who requires frequent ambulation The client who is in protective isolation The client who is actively dying and requires IV pain medication The client who is 3 days postoperative and requires a dressing change

The client who is actively dying and requires IV pain medication The nurse should assume responsibility of this client because IV pain medications should be administered by RNs. Although this client may require less physical care, he may require more emotional care. The nurse should plan to spend extensive time with both the client and his family.

A nurse in a mental health clinic is caring for a client who reports an increase in headaches and confusion over the past month. Medical History Client presented to clinic 5 years ago with generalized feelings of anxiety related to attending college for the first time. No previous history of anxiety or mental health disorders. Family history negative for mental health disorders. Client appeared well groomed and was cooperative with examination. Reported nausea and frequent headaches. Was restless, easily distracted, with sweaty palms. Diagnosed with separation anxiety disorder and ordered Ativan 0.25 mg PO prn daily for 30 days. Client did not request a refill or return for a follow-up visit. Diagnostic Results Severity Measure for Generalized Anxiety Disorder in Adults-34 Physical Examination Vital Signs Temperature 36.6° C (97.9° F) Heart rate 110/min Respiratory rate 24/min Blood pressure 138/94 mm Hg Medication Administration Record Client reports taking no prescription or OTC medications. Nurses Notes 0800: Client is alert and oriented to person, place, time, and situation. Tearful, wringing hands, restless with decreased attention span. Reports nausea, heart palpitations, and a h

The nurse should maintain a calm, nonthreatening demeanor and establish trust by listening to the client's fears and concerns because this client is most likely experiencing severe-to-panic level anxiety. If the client's thinking becomes distorted during the panic stage, the nurse should provide reality orientation to de-escalate the clients anxiety. The nurse should also closely monitor the client for the avoidance of self-care activities, including nutrition and fluid intake, personal hygiene, and sleep.

A nurse on a medical-surgical unit is reconciling a newly admitted client's medication. The nurse is reviewing the process of medication reconciliation with a newly licensed nurse. The nurse should include which of the following information? The American Hospital Association requires accredited facilities to have protocols in place requiring medication reconciliation. The purpose of medication reconciliation is to prevent adverse medication reactions. The nurse who performs medication reconciliation is demonstrating the ethical principal of veracity. The International Council of Nurses Code of Ethics stipulates that the nurse performs medication reconciliation when a client is admitted to a facility, is transferred to another facility, and when a client is discharged from a facility.

The purpose of medication reconciliation is to prevent adverse medication reactions. Medication reconciliation includes reviewing an accurate list of all medications the client is taking and comparing that list to new medications the provider has prescribed. This action decreases the risk of medication interactions and adverse outcomes.

A nurse is caring for a client who was admitted with acute psychosis and is being treated with haloperidol. The nurse should suspect that the client may be experiencing tardive dyskinesia when the client exhibits which of the following? (Select all that apply.) Urinary retention and constipation Tongue thrusting and lip smacking Fine hand tremors and pill rolling Facial grimacing and eye blinking Involuntary pelvic rocking and hip thrusting movements

Tongue thrusting and lip smacking is correct. Individuals who have tardive dyskinesia make repetitive and uncontrollable movements such as tongue thrusting and lip smacking. Facial grimacing and eye blinking is correct. Individuals who have tardive dyskinesia make repetitive and uncontrollable movements such as facial grimacing and eye blinking. Involuntary pelvic rocking and hip thrusting movements is correct. Repetitive, irregular, and involuntary movements of the head, neck, trunk, and extremities can occur in tardive dyskinesia.

A nurse is caring for a client in the emergency department (ED). Nurses' Notes Client comes to the ED with nausea, vomiting, confusion, and tremors. Client is agitated and irritable. Orientated only to self. The client states, "I'm tired of all these people in my house; visiting is over, my mom is dead, and I need to rest before the funeral." The client's partner states the client's mother died 6 years ago. The client's partner states that the client has been drinking "a lot" for the past 6 months. The client agreed to stop drinking 2 days ago. The partner believes that the client's last drink was roughly 36 hr ago. Vital Signs Temperature 99.2°F (37.3o C) Heart rate 90/min Respiratory rate 22/min, Blood pressure 170/95 mm Hg Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing, 2 actions the nurse should take to address that condition, and 2 parameters the nurse should monitor to assess the client's progress. Actions to Take 1 Actions to Take 2 Potential Condition Parameters to Monitor 1 Parameters to Monitor 2 Actions to Take Pad the client's side rails. Administer lorazepam. Provide a safe environment for client a

This client is most likely experiencing alcohol withdrawal syndrome. Therefore, the nurse should administer lorazepam as prescribed for sedation to allow the client to rest and reduce the risk of injury. The nurse should then pad the client's bedrails to prevent injury from potential seizure activity. The nurse should monitor the client for seizure activity because seizures are a potential manifestation of alcohol withdrawal syndrome. The nurse should also monitor the client's fluid and electrolyte status because the client might have fluid and electrolyte disturbances caused using alcohol or as a result of vomiting.

A nurse is caring for a client who is dying. The nurse should incorporate the principle of nonmaleficence into practice by taking which of the following actions? Discussing advance directives with the client and the client's family Providing comfort care measures to the client Withholding a dose of narcotic pain medication when the client has respiratory depression Allowing the client's family unlimited visitation at the time of death

Withholding a dose of narcotic pain medication when the client has respiratory depression The principle of nonmaleficence is an obligation not to inflict harm. It is customary to ease a client's pain via the administration of narcotics. However, if the nurse believes the dose is potentially lethal or could hasten the client's death, the nurse should not administer the medication on the grounds of nonmaleficence.