Nokea
A 14 year-old boy has been admitted to a mental health unit for observation and treatment. The boy becomes agitated and starts yelling at nursing staff members. What should the nurse first response be?
- A. Create an atmosphere of seclusion for the boy according to procedures.
- B. Remove other patients from the area via wheelchairs for added speed.
- C. Ask the patient, 'What is making you mad?'
- D. Ask the patient, 'Why are you doing this, have you thought about what your parents might say?'
Correct Answer: A
Rationale: Seclusion is your best option in this scenario to ensure safety and de-escalation.
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The nurse is caring for a non-English speaking client. The surgeon has asked the nurse to hurry up and prepare the client for their scheduled procedure, which is running late. Which of the following is least appropriate?
- A. Explain to the client's family member that the procedure may be delayed further.
- B. Inform the surgeon that the procedure will be delayed further because getting a staff interpreter will take additional time.
- C. Allow the client's family member to serve as the interpreter.
- D. Ask if a phone-service interpreting service is available to expedite the client preparation.
Correct Answer: C
Rationale: The client's family member should not be relied on as an interpreter.
Which of the following physical findings indicates that an 11-12-month-old child is at risk for developmental dysplasia of the hip?
- A. refusal to walk
- B. not pulling to a standing position
- C. negative Trendelenburg sign
- D. negative Ortolani sign
Correct Answer: B
Rationale: The nurse might be concerned about developmental dysplasia of the hip if an 11-12-month-old child doesn't pull to a standing position. An infant who does not walk by 15 months of age should be evaluated. Children should start walking between 11-15 months of age. Trendelenberg sign is related to weakness of the gluteus medius muscle, not hip dysplasia. Ortolani sign is used to identify congenital subluxation or dislocation of the hip in infants.
An LPN on a Continuous Quality Improvement (CQI) team is tasked with implementing strategies to reduce medication errors. Which of the following strategies would be most beneficial for the LPN to implement?
- A. Track individuals with medication errors and report them to administration.
- B. Remind staff of the five rights of medication administration.
- C. Ensure that all staff members are proficient in completing incident reports if a medication error occurs.
- D. Double check that staff document medication administration in the electronic medical record.
Correct Answer: C
Rationale: Organized, accurate incident reports are important in tracking and understanding why errors occurred. CQI teams use incident reports to create new or build upon existing policies to help standardize medical processes to help reduce errors.
Vaccines provide what type of immunity?
- A. active
- B. passive
- C. transplacental
- D. active and passive
Correct Answer: A
Rationale: Vaccines stimulate the body's immune system to produce antibodies, conferring active immunity. Passive immunity involves transferred antibodies, and transplacental immunity is a form of passive immunity from mother to fetus.
An Rh-negative woman with previous sensitization has delivered an Rh-positive fetus. Which of the following nursing actions should be included in the client's care plan?
- A. emotional support to help the family deal with feelings of guilt about the infant's condition
- B. administration of MICRhoGam to the woman within 72 hours of delivery
- C. administration of Rh-immune globulin to the newborn within 1 hour of delivery
- D. lab analysis of maternal Direct Coombs' test
Correct Answer: A
Rationale: Sensitization means the mother has antibodies against Rh-positive blood, risking hemolytic disease in the fetus. Emotional support is critical to address guilt and concerns about the infant's condition.