Nokea
A child diagnosed with a malignant brain tumor is admitted for removal of the tumor. The nurse should include which action in the plan of care to ensure a safe environment for the child?
- A. Initiating seizure precautions
- B. Using a wheelchair for out-of-bed activities
- C. Assisting the child with ambulation at all times
- D. Minimizing contact with other children on the nursing unit
Correct Answer: A
Rationale: Seizure precautions should be implemented for any child with a brain tumor, both preoperatively and postoperatively. Options 2 and 3 are not required unless functional deficits exist. Based on the child's diagnosis, option 4 is not necessary.
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The nurse is planning a discharge teaching plan for a client who sustained a spinal cord injury. To provide for a safe environment regarding home care, which option should be the priority in the discharge teaching plan?
- A. Assisting the client to deal with long-term care placement
- B. Including the client's significant others in the teaching session
- C. Following up on laboratory and diagnostic tests that were prescribed
- D. Including information the primary health care provider has indicated
Correct Answer: B
Rationale: Involving the client's significant others in discharge teaching is a priority in planning for the client with a spinal cord injury. The client will need the support of the significant others. Knowledge and understanding of what to expect will help both the client and significant others deal with the client's limitations. Long-term placement is not the only option for a client with a spinal cord injury. Laboratory and diagnostic testing are not priority discharge instructions for this client. A primary health care provider's prescription is not necessary for discharge planning and teaching; this is an independent nursing action.
A client asks the nurse to act as a witness for an advance directive. Which is the best intervention for the nurse to implement?
- A. Suggest the nurse manager as a witness.
- B. Agree to sign the document as a witness.
- C. Notify the provider of the client's request.
- D. Help the client find an unrelated third party.
Correct Answer: D
Rationale: An advance directive addresses the withdrawal or withholding of life-sustaining interventions that can prolong life and identifies the person who will make care decisions if the client becomes incompetent. Two people unrelated to the client witness the client's signature and then sign the document signifying that the client signed the advance directive authentically. Nurses or employees of a facility in which the client is receiving care and beneficiaries of the client should not serve as a witness because of conflict of interest concerns. There is no reason to call the provider unless the absence of the advance directive interferes with client care.
The nurse performing an admission assessment notes that a client has been prescribed metoclopramide for a prolonged period. The nurse should immediately call the primary health care provider if which signs/symptoms were then noted by the nurse?
- A. Dry mouth
- B. Anxiety or irritability
- C. Excessive drowsiness
- D. Uncontrolled rhythmic movements of the face or limbs
Correct Answer: D
Rationale: If the client experiences tardive dyskinesia (rhythmic movements of the face or limbs), the nurse should call the primary health care provider because these adverse effects may be irreversible. The medication would be discontinued, and no further doses should be given by the nurse. Anxiety, irritability, and dry mouth are mild side effects that do not harm the client.
A hospitalized client is found lying on the floor next to the bed. Once the client is cared for, the nurse completes an incident report. Which written statements exemplify correct documentation on the report? Select all that apply.
- A. The client fell out of bed.
- B. No bruises or injuries are noted on the client.
- C. The client apparently climbed over the side rails when the nurse was out of the room.
- D. The health care provider was notified that the client was found lying on the floor next to the bed.
- E. The client is alert and oriented and stated that he needed to 'go to the bathroom and didn't want to bother the nurse.'
- F. Vital signs are temperature: 98.6°F (37°C); pulse 78 beats per minute and regular; respirations 16 breaths per minute and regular; blood pressure 188/78 mm Hg.
Correct Answer: B,D,E,F
Rationale: An incident report is a tool used by health care facilities to document situations that have caused harm or have the potential to cause harm to clients, employees, or visitors. The nurse who identifies the situation initiates the report. The report identifies the people involved in the incident, including witnesses; describes the event; and records the date, time, location, factual findings, actions taken, and any other relevant information. The primary health care provider is notified of the incident and completes the report after examining the client. Documentation on the report should always be as factual as possible and needs to avoid accusations. Because the client was found lying on the floor, it is unknown whether the client actually fell out of bed. Additionally, the nurse does not know that the client climbed over the side rails when the nurse was out of the room.
A client has become physically aggressive toward staff and other clients. What action by the nurse will best assure the safety of the milieu while preserving the client's rights?
- A. Sedating the client
- B. Applying wrist restraints
- C. Contacting the client's primary health care provider
- D. Considering all possible alternative measures
Correct Answer: D
Rationale: Before applying restraints, the nurse must exhaust alternative measures to restraints such as a bed alarm, distraction, and a sitter. If the nurse determines that a restraint is necessary, its use is discussed with the client and family, and a prescription is obtained from the primary health care provider. The nurse should explain carefully to the client and family the indications for the restraint, the type of restraint selected, and the anticipated duration for its use. Sedation can be considered as a chemical restraint. The nurse avoids applying the restraint on a client who refused it to prevent client coercion and future charges of battery.