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A charge nurse overhears a staff nurse talking to a nurse from another unit in the hallway. The staff nurse says
- A. I heard that Mr. Smith was admitted for a suicide attempt. Which of the following responses should the charge nurse make?
- B. I will be informing the provider about this conversation.
- C. You should continue this conversation in a private place.
- D. It is an invasion of privacy to discuss that information.
- E. If you are going to talk about a client in public, do not use their name.
Correct Answer: C
Rationale: This response directly addresses the issue of discussing private patient information and reinforces the importance of maintaining confidentiality. By stating that it is an invasion of privacy to discuss the information, the charge nurse makes it clear that such conversations are inappropriate and should not occur.
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A nurse is assisting with the involuntary admission of a client who has an anxiety disorder and is unable to meet their basic physical needs. Which of the following statements should the nurse make to the client?
- A. You have the right to refuse medications prescribed during your stay.
- B. Your admission status allows you to leave the facility at any time.
- C. Your health care team will review your admission status in 90 days.
- D. You will automatically have a legal guardian appointed during this admission.
Correct Answer: A
Rationale: Clients who are involuntarily admitted to a psychiatric facility retain certain rights, including the right to refuse medications. This is an important part of patient autonomy and informed consent. Even though the client is involuntarily admitted, they must still be provided with information about their treatment options and have the right to make decisions about their medications unless there is a court order stating otherwise.
A nurse is caring for a client who is combative and requires wrist restraints. Which of the following actions should the nurse take?
- A. Use a quick-release tie to restrain the client.
- B. Renew the restraint prescription every 48 hr.
- C. Attach the restraints to the side rail of the client's bed.
- D. Maintain 1 fingerbreadth between the restraint and the client's skin.
Correct Answer: A
Rationale: Using a quick-release tie for restraints ensures that the nurse can quickly and easily release the client in case of an emergency. Quick-release ties are designed to provide safety and convenience, allowing healthcare providers to promptly respond to the client's needs without compromising safety.
A nurse is reinforcing teaching with a client who is scheduled for implantation of a vagus nerve stimulator. Which of the following statements should the nurse include in the teaching?
- A. You might have extreme fatigue for several weeks after the device is implanted.
- B. Your voice might sound hoarse after the device is implanted.
- C. Your depression will improve within 72 hours after the device is implanted.
- D. You can schedule an appointment with your provider to turn the device off.
Correct Answer: B
Rationale: Hoarseness or changes in voice is a common side effect after the implantation of a vagus nerve stimulator. The stimulator affects the vagus nerve, which is close to the vocal cords. As a result, stimulation can lead to changes in voice, including hoarseness. Patients should be informed of this potential side effect so they are not alarmed if it occurs.
A nurse is reinforcing teaching with a client who has a new prescription for a nicotine transdermal system. Which of the following statements should the nurse make?
- A. A decrease in appetite is expected when beginning treatment.
- B. Using this medication will help minimize symptoms of withdrawal.
- C. Expect to stop smoking immediately after starting this medication.
- D. Apply a new patch every 4 hours until your cravings diminish.
Correct Answer: B
Rationale: Nicotine replacement therapy, including the nicotine transdermal system, is designed to help minimize symptoms of nicotine withdrawal. These symptoms can include cravings, irritability, anxiety, and difficulty concentrating. By providing a controlled release of nicotine, the transdermal system helps reduce the intensity of withdrawal symptoms and supports the quitting process.
A nurse is collecting data from a client who has been admitted with manifestations of paranoia. Which of the following findings should the nurse identify as a risk factor for schizophrenia?
- A. The client's home has lead paint on the walls.
- B. The client's twin sibling has schizophrenia.
- C. The client is opioid dependent.
- D. The client's mother used tobacco products during pregnancy.
Correct Answer: B
Rationale: Having a family member, especially a twin sibling, with schizophrenia significantly increases the risk of developing the condition. Genetics play a crucial role in the development of schizophrenia, and individuals with a first-degree relative who has schizophrenia are at a higher risk of developing the disorder.