Nokea
A client asks the nurse to call the police and states: "I need to report that I am being abused by a nurse." The nurse should first
- A. focus on reality orientation to place and person
- B. assist with the report of the client's complaint to the police
- C. obtain more details of the client's claim of abuse
- D. document the statement on the client's chart with a report to the manager
Correct Answer: C
Rationale: Obtain more details of the client's claim of abuse. The advocacy role of the professional nurse, as well as the legal duty of the reasonable prudent nurse, requires the investigation of claims of abuse to ensure appropriate action and protection for the client.
You may also like to solve these questions
An unlicensed assistive personnel (UAP), who usually works on a surgical unit is assigned to float to a pediatric unit. Which question by the charge nurse would be most appropriate when making delegation decisions?
- A. How long have you been a UAP and what units you have worked on?
- B. What type of care do you give on the surgical unit and what ages of clients?
- C. What is your comfort level in caring for children and at what ages?
- D. Have you reviewed the list of expected skills you might need on this unit?
Correct Answer: D
Rationale: The UAP must be competent to accept the delegated task. Review of skills needed versus level of performance is the most efficient and effective way to determine this.
All of the following are causes of vaginal bleeding in late pregnancy except:
- A. placenta previa.
- B. eclampsia.
- C. abruptio placentae.
- D. uterine rupture.
Correct Answer: B
Rationale: Eclampsia is a disorder of pregnancy characterized by hypertension, proteinuria, and edema. This condition can cause seizure and/or coma. Choices 1 and 3 are abnormal conditions that can cause bleeding, particularly in the third trimester. Choice 4 is a major obstetrical emergency that can cause bleeding internally and externally.
The nurse confides to a coworker that when reporting a change in the client's condition to the HCP, the HCP stated, "It seems that every time you work, there is some catastrophe. Can't you problem-solve earlier so this doesn't happen!" What is the coworker's best response?
- A. "This HCP responds to everyone the same. You did everything right; don't feel bad."
- B. "You should obtain our hospital policy and initiate the steps to report the HCP."
- C. "Let the nurse manager know; I think our manager is already dealing with the HCP."
- D. "Let's go to the medical director, who should be told about this HCP's angry response."
Correct Answer: B
Rationale: Reporting the HCP's uncivil behavior per hospital policy is the best response to address and document the issue appropriately.
A client is diagnosed with methicillin resistant staphylococcus aureus pneumonia (MRSA). What type of isolation is most appropriate for this client?
- A. Reverse
- B. Airborne
- C. Standard precautions
- D. Contact
Correct Answer: D
Rationale: Contact precautions or Body Substance Isolation (BSI) involves the use of barrier protection (e.g. gloves, mask, gown, or protective eyewear as appropriate) whenever direct contact with any body fluid is expected.
A patient has experienced a severe third degree burn to the trunk in the last 36 hours. Which phase of burn management is the patient in?
- A. Shock phase
- B. Emergent phase
- C. Healing phase
- D. Wound proliferation phase
Correct Answer: A
Rationale: The shock phase is considered the first 24-48 hours in burn wound management.