Nokea
A client is admitted to a voluntary hospital mental health unit due to suicidal ideation. The client has been on the unit for 2 days and now states, 'I demand to be released now!' The appropriate action is for the nurse to:
- A. You cannot be released because you are still suicidal.
- B. You can be released only if you sign a no-suicide contract.
- C. Let's discuss your decision to leave and then we can prepare you for discharge.
- D. You have a right to sign out as soon as we get an order from the healthcare provider's discharge order.
Correct Answer: C
Rationale: The correct action for the nurse in this scenario is to engage the client in a discussion about their decision to leave and then prepare them for discharge. This approach allows the nurse to assess the client's current state, address concerns, and plan for a safe discharge. Option A is incorrect because it does not involve a therapeutic communication approach and may escalate the situation. Option B is incorrect as it places a condition on the client for release, which is not recommended in this situation. Option D is incorrect as it does not prioritize the client's autonomy and right to make decisions about their care.
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The patient has been diagnosed with diabetes. When admitted, the patient is unkempt and is in need of a bath and foot care. When questioned about hygiene habits, the nurse learns the patient takes a bath once a week and a sponge bath every other day. To provide ultimate care for this patient, which principle should the nurse keep in mind?
- A. Patients who appear unkempt may require guidance on hygiene practices.
- B. Personal preferences can be influenced by health conditions.
- C. The patient's illness may require teaching of new hygiene practices.
- D. Cultural perspectives on cleanliness can vary based on health status.
Correct Answer: C
Rationale: In this scenario, the patient's diagnosis of diabetes may necessitate adjustments to their hygiene practices. The nurse should recognize that certain illnesses, like diabetes, can impact hygiene needs. Choice A is incorrect because appearing unkempt does not necessarily indicate a lack of importance on hygiene practices; it may be due to various factors. Choice B is incorrect as health conditions can influence personal preferences and habits. Choice D is incorrect as cultural views on cleanliness are not the primary focus when addressing hygiene practices related to a specific illness.
A healthcare provider is providing discharge teaching to a client about self-administering heparin.
- A. Administer medication in the abdomen.
- B. Administer medication in the thigh.
- C. Administer medication in the upper arm.
- D. Administer medication in the buttock.
Correct Answer: A
Rationale: Heparin is typically administered in the abdomen for self-injection to avoid muscle tissue and for better absorption. The subcutaneous tissue in the abdomen provides a larger area for injection and is usually recommended for heparin administration. Administering heparin in the thigh, upper arm, or buttock may not be as effective or safe as the abdomen due to variations in absorption rates and potential risks associated with muscle injection.
When obtaining a urine specimen for a culture and sensitivity from an indwelling catheter, the nurse should:
- A. Cleanse the entry port prior to withdrawing urine.
- B. Use a sterile syringe to collect urine from the collection bag.
- C. Obtain the specimen from the drainage tubing.
- D. Replace the catheter before obtaining the specimen.
Correct Answer: A
Rationale: The correct procedure when obtaining a urine specimen from an indwelling catheter for culture and sensitivity is to cleanse the entry port before withdrawing urine. This step helps reduce the risk of contamination and ensures the accuracy of the results. Option B is incorrect because using a sterile syringe to collect urine from the collection bag is not the recommended method for obtaining a catheter specimen. Option C is incorrect as obtaining the specimen from the drainage tubing is not the appropriate technique for collecting a urine sample from an indwelling catheter. Option D is incorrect because replacing the catheter before obtaining the specimen is not necessary and may introduce unnecessary complications.
A client has been coughing for 3 weeks and is beginning to cough up blood. The client has manifestations of which of the following conditions?
- A. Allergic reaction
- B. Ringworm
- C. Systemic lupus erythematosus
- D. Tuberculosis
Correct Answer: D
Rationale: The correct answer is D: Tuberculosis. Coughing up blood (hemoptysis) is a key symptom of tuberculosis. Tuberculosis is a respiratory infection caused by the bacterium Mycobacterium tuberculosis. The other options are incorrect because an allergic reaction typically involves symptoms like itching, hives, or swelling, not coughing up blood. Ringworm is a fungal skin infection characterized by a red, circular rash, and systemic lupus erythematosus is an autoimmune disease that primarily affects joints and skin without causing hemoptysis.
A nurse is preparing to provide tracheostomy care for a client. Which of the following actions should the nurse take first?
- A. Perform hand hygiene
- B. Identify the client using two identifiers
- C. Prepare the sterile field
- D. Don sterile gloves
Correct Answer: A
Rationale: Performing hand hygiene is essential before any direct patient care procedure to prevent the spread of infection. Proper hand hygiene helps reduce the risk of introducing harmful microorganisms to the client, especially when dealing with a procedure like tracheostomy care. Identifying the client, preparing the sterile field, and donning sterile gloves are all important steps in tracheostomy care, but hand hygiene precedes them to maintain asepsis and ensure patient safety.