Nokea
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.
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The nurse notes old and new ecchymotic areas on an older adult client's arms and buttocks upon admission. The client states to the nurse in confidence that the family members frequently hit him. Which therapeutic statement should the nurse communicate in response?
- A. I have a legal obligation to report this type of abuse.
- B. Let's get these treated, and I will maintain confidence.
- C. Let's talk about ways to prevent someone from hitting you.
- D. If this happens again, you must call the emergency department.
Correct Answer: A
Rationale: The nurse should inform the client that nurses cannot maintain confidence about alleged abusive behavior and that the nurse must report situations related to abuse. The nurse avoids bargaining with the client about treatment to maintain a confidence that the nurse is legally bound to report. Options 3 and 4 delay protective action and place the client at risk for future abuse.
The nurse manager is planning to implement needed changes in the method of the documentation system for the nursing unit. Which should be the initial step in the process of change for the nurse manager?
- A. Plan strategies to implement the change.
- B. Set goals and priorities regarding the change process.
- C. Identify the inefficiency that needs improvement or correction.
- D. Identify potential solutions and strategies for the change process.
Correct Answer: C
Rationale: When beginning the change process, the nurse should identify and define the problem that needs improvement or correction. This important first step can prevent many future problems because, if the problem is not correctly identified, a plan for change may be aimed at the wrong problem. This is followed by goal setting, prioritizing, and identifying potential solutions and strategies to implement the change.
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.
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.
The nurse should plan to wear this protective device when caring for hospitalized clients with which diagnosed disorders? (Refer to the figure.) Select all that apply.
- A. Scabies
- B. Tuberculosis
- C. Hepatitis A virus
- D. Pharyngeal diphtheria
- E. Streptococcal pharyngitis
- F. Meningococcal pneumonia
Correct Answer: D,E,F
Rationale: A standard surgical mask is used as part of droplet precautions to protect the nurse from acquiring the client's infection. Droplet precautions refer to precautions used for organisms that can spread through the air but are unable to remain in the air farther than 3 feet. Many respiratory viral infections such as respiratory viral influenza require the use of a standard surgical mask when caring for the client. Some other disorders requiring the use of a standard surgical mask include pharyngeal diphtheria; rubella; streptococcal pharyngitis; pertussis; mumps; pneumonia, including meningococcal pneumonia; and the pneumonic plague. Scabies and hepatitis A are transmitted by direct contact with an infected person and require the use of contact precautions for protection. Tuberculosis requires the use of airborne precautions and the use of an individually fitted particulate filter mask. A standard surgical mask would not protect the nurse from Mycobacterium tuberculosis.