Nokea
A 16-year-old emancipated client is being seen in the emergency department following a minor automobile accident. The client’s parents arrive and are asking about the client’s laboratory results. Which response is best for the nurse to provide?
- A. The healthcare provider will share this information with you.'
- B. I’m sorry, but your child’s medical information is none of your business.'
- C. I can give you those results as soon as I get them back from the laboratory.'
- D. I can only give medical information to your child because they are legally an adult.'
Correct Answer: D
Rationale: Emancipated minors have autonomy.
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The nurse enters a client’s room to perform a physical assessment and finds the client crying. Which response is best for the nurse to provide?
- A. Gives the client a hug and says, 'It’s okay to cry when you are sad.'
- B. While touching the client’s forearm, asks, 'Would you like to talk about it?'
- C. I’m sorry to disturb you at a difficult time. This can wait until later.'
- D. This is a bad time. I can see you are upset. I can come back later.'
Correct Answer: B
Rationale: Empathy encourages communication.
What times should the nurse measure vital signs? Select all that apply.
- A. 1500
- B. 1600
- C. 1800
- D. 1000
- E. 1200
Correct Answer: A,B,C,D,E,F,G
Rationale: Context-dependent; typically every 4 hours.
To assess the quality of the client’s abdominal pain, which approach should the nurse use?
- A. Provide a numeric pain scale.
- B. Ask the client to describe the pain.
- C. Observe body language and movement.
- D. Identify effective pain relief measures.
Correct Answer: B
Rationale: Descriptive assessment captures pain quality.
After completing daily charting at 1400, the nurse realizes that a 0900 occurrence was not entered. Which is the best way for the nurse to enter computer documentation of the 0900 occurrence?
- A. Request removal initiated by the Health Information Manager.
- B. Make an electronic addendum following the 1400 documentation.
- C. Create an electronic correction after 1400 notes are officially unlocked.
- D. Enter the occurrence after the 1400 notes and identify as 'late entry.'
Correct Answer: D
Rationale: Late entries maintain accuracy.
A confused older adult client is having trouble sleeping at night and is sometimes found wandering in the hallway. Which nursing intervention should the nurse implement first?
- A. Administer a PRN sedative prescription.
- B. Leave the door to the client’s room open slightly.
- C. Apply wrist restraints to prevent wandering.
- D. Provide a back rub at bedtime.
Correct Answer: B
Rationale: Back rub addresses agitation non-pharmacologically.