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A client is admitted to the psychiatric unit after a suicide attempt. The nurse should plan which intervention as the most important to maintain client safety?
- A. Assigning a staff member to remain with the client at all times.
- B. Requesting that the client promise to alert staff of suicidal thoughts.
- C. Removing the client's personal clothing and replacing them with a hospital gown.
- D. Placing the client in a seclusion room where all dangerous articles are removed.
Correct Answer: A
Rationale: Hanging is a serious suicide attempt. The plan of care must reflect the action that will promote the client's safety. Constant observation by a staff member is necessary. It is not advisable to rely on the client to report suicidal thoughts at this point in the treatment. Removing one's clothing does not maximize all possible safety strategies. Placing the client in seclusion further isolates the client.
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The nurse gives medical information regarding the client's condition to a person who is assumed to be a family member. Later the nurse discovers that this person is not a family member and realizes that this violated which legal concepts of the nurse-client relationship? Select all that apply.
- A. Duty to provide care
- B. Client's right to privacy
- C. Client's right of autonomy
- D. Client's right to confidentiality
- E. Duty to comply with nursing standards
Correct Answer: B,D
Rationale: Discussing a client's condition without client permission violates a client's rights to privacy and confidentiality and places the nurse in legal jeopardy. This action by the nurse is both an invasion of privacy and affects the confidentiality issue with client rights. Options 1, 3, and 5 do not represent violation of the situation presented.
A client with a diagnosis of schizophrenia and psychosis is pacing, agitated, and presenting with aggressive gestures. The client's speech pattern is rapid, and the client's affect is belligerent. Which priority nursing intervention based on these objective data should the nurse implement?
- A. Provide safety for the client and other clients on the unit.
- B. Bring the client to a less stimulated area to regain control.
- C. Provide the clients on the unit with a sense of comfort and safety.
- D. Assist the staff in caring for the client in a controlled environment.
Correct Answer: A
Rationale: If a client is exhibiting signs that indicate loss of control, the nurse's immediate priority is to ensure safety for all clients. Option 1 is the only option that addresses the client's and other clients' safety needs. Option 2 addresses the client's needs. Option 3 addresses other clients' needs. Option 4 is not client centered.
The nurse places a hospitalized client with a diagnosis of active tuberculosis in a private, well-ventilated isolation room. In addition, which action should the nurse take before entering the client's room?
- A. Wash the hands.
- B. Wash the hands and wear a gown and gloves.
- C. Wash the hands and place a high-efficiency particulate air (HEPA) respirator over the nose and mouth.
- D. The nurse needs no special precautions, but the client is instructed to cover his or her mouth and nose when coughing or sneezing.
Correct Answer: C
Rationale: Tuberculosis is a highly communicable disease caused by Mycobacterium tuberculosis. The nurse wears a HEPA respirator when caring for a client with active tuberculosis. Hands are always thoroughly washed before and after caring for the client. Option 1 is an incomplete action. Option 2 is also inaccurate and incomplete. Gowning is only indicated when there is a possibility of contaminating clothing. Option 4 is an incorrect statement because special precautions are needed.
A primary health care provider has written a prescription to administer methylergonovine maleate to a postpartum client. The nurse should contact the primary health care provider to verify the prescription if which condition is present in the mother?
- A. Hypertension
- B. Excessive lochia
- C. Difficulty locating the uterine fundus
- D. Excessive bleeding and saturation of more than one peripad per hour
Correct Answer: A
Rationale: Methylergonovine maleate is an ergot alkaloid used to treat uterine atony. It is contraindicated for the hypertensive woman, individuals with severe hepatic or renal disease, and during the third stage of labor. Excessive lochia, a uterine fundus that is difficult to locate, and excessive bleeding are clinical manifestations of uterine atony indicating the need for methylergonovine.
A new nurse is learning the functions of the unit's nurse manager. Which functions are included? Select all that apply.
- A. Recruiting new employees
- B. Conducting regular staff meetings
- C. Assisting staff in meeting annual goals
- D. Monitoring professional standards of practice on the nursing unit
- E. Delegating problem-solving of client or family complaints to all nursing staff
- F. Writing prescriptions for primary health care providers (HCPs) when conducting rounds
Correct Answer: A,B,C,D
Rationale: Responsibilities of the nurse manager (middle manager) include recruiting new employees (interviewing and hiring), conducting regular staff meetings, assisting staff in meeting annual goals for the unit and systems needed to accomplish goals, monitoring professional standards of practice on the nursing unit, developing an ongoing staff development plan, conducting routine staff evaluations, acting as a role model, submitting staff schedules for the unit, conducting regular client rounds and problem-solving client and family complaints, establishing and implementing a unit quality improvement plan, and conducting rounds with primary HCPs. The nurse is not responsible for writing prescriptions for HCPs when conducting rounds; the HCP is responsible for writing prescriptions.