Nokea
A client is being treated for paranoid schizophrenia. When the client became loud and boisterous, the nurse immediately placed him in seclusion as a precautionary measure. The client willingly complied. The nurse's action
- A. may result in charges of unlawful seclusion and restraint
- B. leaves the nurse vulnerable for charges of assault and battery
- C. was appropriate in view of a client history of violence
- D. was necessary to maintain the therapeutic milieu of the unit
Correct Answer: A
Rationale: Seclusion should only be used when there is an immediate threat of violence or threatening behavior toward the staff, the other clients, or the client himself.
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The nurse is to move a client up in bed without any help. Where should the nurse place the client's pillow?
- A. At the bottom of the bed
- B. On the bedside stand
- C. At the head of the bed
- D. Under the client's head
Correct Answer: C
Rationale: Placing the pillow at the head of the bed supports the client's head after moving up, ensuring comfort and proper positioning.
A baby girl is born with a meningomyelocele. To prevent trauma to the sac, the nurse should place the infant:
- A. Supine and flat
- B. Prone with the hips slightly elevated
- C. Prone with the head slightly elevated
- D. Side lying
Correct Answer: B
Rationale: Placing the infant prone with hips slightly elevated protects the meningomyelocele sac from trauma and pressure.
The mother of a child with cystic fibrosis asks the nurse for information about the disease. The nurse's teaching is based on the knowledge that cystic fibrosis:
- A. Produces multiple cysts in the lungs
- B. Affects the exocrine glands
- C. Is an autosomal dominant disorder
- D. Affects the endocrine glands
Correct Answer: B
Rationale: Cystic fibrosis affects exocrine glands, causing thick mucus secretions, so B is correct. It does not produce lung cysts , is autosomal recessive, not dominant , and does not affect endocrine glands .
The nurse is preparing a five-year-old child for surgery.
- A. What is the best action for the nurse when the informed consent for a five-year-old’s surgery is signed by the mother, and the parents are divorced with joint legal custody?
- B. Notify the physician.
- C. Inform surgery.
- D. Contact the father to obtain consent.
- E. Continue the child’s preoperative preparation.
Correct Answer: D
Rationale: In cases of joint legal custody, consent from either parent is sufficient for surgical procedures. Since the mother has signed the informed consent, no further action is needed, and the nurse should continue preoperative preparation. Notifying the physician, informing surgery, or contacting the father is unnecessary.
The nurse counsels a 70-year-old woman who comes to the outpatient clinic for a routine examination.
- A. What should the nurse suspect in a 70-year-old woman taking laxatives twice daily and a suppository once daily?
- B. Has an anal fixation resulting from recent loss of her husband.
- C. Is depressed due to alterations in inTest inal absorption and excretion.
- D. Is experiencing excessive concern with body function due to physical changes.
- E. Has regressed due to a fear of losing the ability to have bowel movements.
Correct Answer: C
Rationale: Excessive laxative use in a 70-year-old likely reflects overconcern with bowel function, common in elderly patients facing physical changes like constipation. There’s no evidence of anal fixation, depression, or regression in the scenario.