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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 nurse admits a 7 year-old to the emergency room after a leg injury. The x-rays show a femur fracture near the epiphysis. The parents ask what will be the outcome of this injury. The appropriate response by the nurse should be which of these statements?
- A. The injury is expected to heal quickly because of thin periosteum.
- B. In some instances the result is a retarded bone growth.
- C. Bone growth is stimulated in the affected leg.
- D. This type of injury shows more rapid union than that of younger children.
Correct Answer: B
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
A client with a chest tube following thoracic surgery needs care. Which task should the nurse delegate to an assistive personnel?
- A. Teach deep breathing and coughing to the client.
- B. Assist the client to select food choices from the menu.
- C. Evaluate the client's response to pain medication.
- D. Monitor the characteristics of the client's chest tube drainage.
Correct Answer: B
Rationale: The correct answer is B because assisting the client with food choices is a task that can be safely delegated to assistive personnel. This task does not require nursing judgment or specialized skills. Choices A, C, and D involve assessing the client's condition, response to treatment, and monitoring critical aspects of care, which are nursing responsibilities that necessitate specialized knowledge and judgment. Teaching deep breathing and coughing (A), evaluating pain medication response (C), and monitoring chest tube drainage (D) require a higher level of training and expertise that should be performed by the nurse.
A client with type 2 diabetes mellitus is receiving metformin (Glucophage). Which laboratory test should the LPN/LVN monitor while the client is taking this medication?
- A. Complete blood count (CBC)
- B. Liver function tests
- C. Serum electrolytes
- D. Renal function tests
Correct Answer: B
Rationale: The correct answer is B: Liver function tests. While a client is taking metformin, monitoring liver function tests is crucial to assess for potential hepatic side effects. Metformin is primarily eliminated by the liver, and monitoring liver function tests helps in early detection of any liver-related complications. Choices A, C, and D are incorrect. A complete blood count (CBC) is not specifically required for monitoring metformin therapy. Serum electrolytes are not directly impacted by metformin, making it less relevant for monitoring this medication. Renal function tests are important for some other diabetes medications, but in the case of metformin, liver function tests take precedence due to its hepatic metabolism.
A healthcare professional is reviewing measures to prevent back injuries with assistive personnel (AP). Which of the following instructions should the healthcare professional include?
- A. When lifting an object, spread your feet apart to provide a wide base of support.
- B. Always lift objects with your back straight and not your legs.
- C. Avoid using any assistive devices.
- D. Bend at the waist to reach objects.
Correct Answer: A
Rationale: The correct instruction to prevent back injuries while lifting is to spread your feet apart to provide a wide base of support. This helps in maintaining stability and reduces the risk of back injury. Choice B is incorrect as lifting objects with your back straight and using your legs is the recommended technique. Choice C is incorrect because assistive devices can actually help prevent back injuries by providing support. Choice D is incorrect as bending at the waist to reach objects can strain the back muscles and increase the risk of injury.
A nurse is in a public building when someone cries out, 'Help! I think he is having a heart attack!' The nurse responds to the scene and finds the unconscious adult lying on the floor. Another bystander has obtained an AED. The nurse's first action, after ensuring someone has called for EMS, should be to:
- A. Administer cardiac compressions
- B. Attach the AED pads to the client
- C. Check for a pulse
- D. Perform rescue breaths
Correct Answer: A
Rationale: In a scenario where a person is unconscious and there is an indication of a possible heart attack, the immediate priority for the nurse should be to administer cardiac compressions. This action helps maintain circulation and ensures oxygenated blood reaches vital organs until the AED is available. Checking for a pulse or performing rescue breaths may delay essential circulation support, and attaching AED pads should follow the initial step of administering compressions to maximize the chances of a successful resuscitation.