Management EAQ - Answers I missed
What is the most appropriate approach for the school nurse to take regarding children who are to be given medications while in school? 1. Assuring the children that their privacy will be respected 2. Teaching each class about taking medications in the school setting 3. Encouraging the children to tell their friends that they are taking a medication 4. Asking teachers to answer questions when other students ask about medications given in school
1. Assuring the children that their privacy will be respected Children's and adults' confidentiality is protected by privacy laws. Although health classes may address medication as part of its curriculum, the information should be taught on a general, not a personal, level. Children and their teachers should not be encouraged to divulge private information.
A client with mental health problems is given a prescription for fluphenazine (Prolixin). The nurse develops a teaching plan about the medication. What should the nurse caution the client to avoid? 1. Eating cheeses 2. Nighttime driving 3. Staying in the sun 4. Taking drugs containing aspirin
3. Staying in the sun Fluphenazine causes photosensitivity; severe sunburn may occur with exposure to the sun. There are no known side effects of fluphenazine (Prolixin) that affect the ability to drive at night. The client should avoid eating cheese if she is taking a monoamine oxidase inhibitor, not fluphenazine, which is a phenothiazine. Aspirin is not contraindicated for clients taking fluphenazine.
A client with Laënnec cirrhosis has ascites and jaundice and is confused. What is the nursing priority when caring for this client? 1. Correcting nutritional deficiencies 2. Measuring abdominal girth every day 3. Providing for the client's physical safety 4. Placing the client in the high-Fowler position
3. Providing for the client's physical safety Hepatic encephalopathy, related to high ammonia levels, results in central nervous system derangement; physical safety is the priority. Although correcting nutritional deficiencies is important, it is not the priority. Although measuring abdominal girth is important, it is not the priority. The high-Fowler position will be uncomfortable because of the pressure of the distended abdomen against the legs; the semi-Fowler position is more appropriate and it promotes respiration.
What is the school nurse's most important action when monitoring an adolescent who has just returned to high school after a suicide attempt? 1. Observing the adolescent with frequent summonses to the health office 2. Requesting that teachers and friends report any changes in the client's behavior 3. Speaking with the adolescent regarding any feelings he has about returning to school 4. Telling the teachers what happened and having them ask whether there are any problems
3. Speaking with the adolescent regarding any feelings he has about returning to school Speaking with the adolescent regarding any feelings he has about returning to school shows the adolescent that the nurse is available and is interested and concerned. Observing the adolescent with frequent summonses to the health office will draw too much attention to the adolescent; also, it is demeaning. Requesting that teachers and friends report any changes in behavior will place responsibility on others and may interfere with the adolescent's relationship with them. Also, it violates the adolescent's right to privacy. Telling the teachers what happened and having them ask whether there are any problems violates the adolescent's right to privacy.
An adult client with schizophrenia is involuntarily admitted to the psychiatric unit. While off the unit for needed testing, the client runs away. Legally, who should the nurse notify immediately? 1. Probate judge 2. Client's family 3. Client's psychiatrist 4. Law enforcement officer
4. Law enforcement officer Legally it is the responsibility of the staff to notify law enforcement officers so the client can be apprehended. A judge may be involved later in a nonemergency situation. Although the other family and psychiatrist will be notified eventually, neither is the priority.
A client with a history of schizophrenia has recently begun reporting symptoms of depression and is now being prescribed a selective serotonin reuptake inhibitor (SSRI). In light of the information in the client's chart, the nurse's priority is: 1. Educating both the client and family on how to identify the early signs of extrapyramidal symptoms 2. Requesting a gastrointestinal consult to identify the cause of the client's need for frequent antacids 3. Stressing the importance of managing the client's diet while taking the prescribed antidepressant 4. Discuss the stressors that have developed since the client moved in with his sister and brother-in-law
1. Educating both the client and family on how to identify the early signs of extrapyramidal symptoms Extrapyramidal symptoms can result from antipsychotic medication therapy, and the risk is increased when the treatment plan includes an SSRI antidepressant. The cause of the frequent use of antacids should be explored but does not take priority in this situation. A well-balanced diet is always important, but the importance of diet management would still exist if the antidepressant were an MAOI and not an SSRI. Identifying and addressing stressors is important, but it does not take priority in this situation.
A nurse is caring for a child with acute lymphoid leukemia who is undergoing chemotherapy. The parents ask why the child needs prednisone. How should the nurse respond? 1. It decreases inflammation. 2. Production of lymphocytes is suppressed. 3. It increases appetite and a sense of well-being. 4. Irradiation skin irritation and edema are reduced.
1. It decreases inflammation. Prednisone is a synthetic glucocorticoid that exerts an active antiinflammatory effect by stabilizing lysosomal membranes, thereby inhibiting proteolytic enzyme release. Prednisone does not affect the lymphocytes. Although prednisone increases the appetite and creates a sense of well-being, these are not the reasons it is administered. There is no indication the child is receiving radiation.
A 13-year-old girl tells the school nurse that she has taken a pregnancy test and gotten a positive result. She adds that her grandfather has been molesting her for the past 3 years. When the nurse asks whether anyone else knows about this, she replies, "Yes, but my mother doesn't believe me." Who is the nurse legally required to notify? 1. Police, concerning a possible sex crime 2. Child protective services, for immediate intervention 3. The clinic, for an examination to confirm the pregnancy 4. The girl's mother, regarding the pregnancy test's positive result
2. Child protective services, for immediate intervention It is the nurse's legal responsibility to report child abuse to the appropriate agency. Although the police may be notified, this is not the nurse's responsibility at this time. An examination to confirm the pregnancy may be arranged later; it is not the priority. The nurse has not yet verified the girl's pregnancy; at this time it is most important to protect her from further abuse
A client with schizophrenia who was admitted involuntarily to a psychiatric facility runs away. The nurse's first action is to notify the: 1. Client's family that the client has left the hospital 2. Law enforcement officers of the client's elopement 3. Client's psychiatrist after discovering that the client has gone 4. Practitioner who certified the client's need for hospitalization
2. Law enforcement officers of the client's elopement Legally it is the responsibility of the staff to notify law enforcement officers so the client can be found and returned. The staff should notify the family, but this is not the first intervention. Although the client's psychiatrist will be notified, it is not the priority at this time. Although the practitioner may appreciate being notified, it is not the priority.
A 15-year-old emancipated minor gave birth to a boy 36 hours ago and has requested a circumcision. What is the medical priority? 1. Getting a physician's prescription for a lidocaine injection 2. Educating the new mother about the circumcision procedure 3. Getting an informed consent signed by the mother of the baby 4. Getting an informed consent signed by the grandmother of the baby
3. Getting an informed consent signed by the mother of the baby As an emancipated minor, the mother of the baby has the right to make the decision regarding the circumcision and is responsible for signing the informed consent. A nurse does not administer a lidocaine injection into the newborn penis; the physician does. Circumcision is a decision made by the parent(s), often for cultural or religious reasons. Education can be provided as needed, as the provider obtains a signed consent. Because the mother of the baby is an emancipated minor, the grandmother does not have the authority to sign the consent in this situation.