Nokea
A client is found lying on the floor near the bathroom door, stating, 'I thought I could get up on my own.' What information must the nurse document in this situation?
- A. A statement explaining the condition the client was found in, quoting the client's words about the situation
- B. An explanation of how the fall happened and when the physician was notified
- C. An account of the conditions of the room that contributed to the client's fall
- D. A summary of the client's medical history and current medications
Correct Answer: A
Rationale: The correct answer is A because documenting the client's own words provides direct evidence of their condition and thought process at the time of the incident. This helps in understanding the client's perspective and decision-making, which is crucial for providing appropriate care and preventing future falls.
Choice B is incorrect because while it may be important to document how the fall happened and when the physician was notified, it does not directly capture the client's own words and thoughts.
Choice C is incorrect as it focuses on the conditions of the room rather than the client's own account of the situation.
Choice D is also incorrect as it pertains to the client's medical history and medications, which are important but not directly relevant to documenting the client's immediate situation and actions.
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Which of the following types of antipsychotic medications is most likely to produce extrapyramidal effects?
- A. Atypical antipsychotic drugs
- B. First-generation antipsychotic drugs
- C. Third-generation antipsychotic drugs
- D. Dopamine system stabilizers
Correct Answer: B
Rationale: The correct answer is B: First-generation antipsychotic drugs. These medications primarily block dopamine receptors in the brain, leading to extrapyramidal effects such as dystonia, akathisia, parkinsonism, and tardive dyskinesia. These side effects are less common with atypical antipsychotic drugs (choice A) due to their different receptor profiles. Third-generation antipsychotic drugs (choice C) and dopamine system stabilizers (choice D) are newer classes of medications with reduced extrapyramidal effects compared to first-generation drugs. Therefore, the most likely culprit for producing extrapyramidal effects among the options provided is the first-generation antipsychotic drugs.
Which example best describes a nurse who exhibits moral courage?
- A. A nurse feels angry when a parent refuses important treatment for his child.
- B. A nurse considers seeking help for depression when she feels she cannot meet the needs of her clients in the oncology unit.
- C. A nurse contacts a physician for further orders when he fails to order comfort measures for a client with a terminal illness.
- D. A nurse is frustrated when the laboratory is slow in responding to an order for a stat blood glucose.
Correct Answer: C
Rationale: The correct answer is C because it demonstrates moral courage by advocating for the client's well-being in the face of potential conflict with the physician. By taking action to ensure the comfort of a terminally ill client, the nurse upholds ethical principles. Choice A reflects emotional response, not moral courage. Choice B focuses on personal issues, not professional courage. Choice D involves frustration, not moral courage.
Which of the following is an example of whistle-blowing?
- A. A nurse contacts administration about a colleague who takes supplies to use for a mission trip
- B. A client sues a nurse because she failed to call the physician about his wound infection
- C. A nursing assistant calls for help when a client falls out of bed
- D. A client developed a sacral pressure ulcer when he was not turned in bed for over four hours
Correct Answer: A
Rationale: The correct answer is A because whistle-blowing involves reporting unethical or illegal behavior within an organization to higher authorities. In this scenario, the nurse is reporting a colleague's misuse of supplies for personal gain, which is unethical. Choice B involves a client suing a nurse for malpractice, not whistle-blowing. Choice C is a standard response to a client falling and does not involve reporting unethical behavior. Choice D describes a case of neglect, not whistle-blowing.
According to HIPAA, which of the following is considered an individual right for privacy of a client's protected health information?
- A. The right to receive a copy of the organization's privacy practices
- B. The right to receive medical bills for care received
- C. The right to change personal health information
- D. An understanding that protected health information will only be used in regards to client treatments
Correct Answer: A
Rationale: The correct answer is A: The right to receive a copy of the organization's privacy practices. This is because under HIPAA, individuals have the right to be informed about how their protected health information is being used and disclosed. Providing clients with a copy of the organization's privacy practices ensures transparency and empowers them to understand their rights regarding their health information.
Choices B, C, and D are incorrect:
B: The right to receive medical bills for care received - This is not a specific right related to privacy of protected health information under HIPAA.
C: The right to change personal health information - Individuals have the right to request amendments to their health information, but this is not directly related to privacy rights.
D: An understanding that protected health information will only be used in regards to client treatments - While this is an important principle under HIPAA, it does not specifically address individual rights related to privacy practices.
A nurse is performing an end-of-shift count of narcotics kept in the locked cabinet. The narcotic log states there should be 26 oxycodone pills left, but there are only 24 in the drawer. What is the first action of the nurse?
- A. Perform the count again
- B. Contact the pharmacy to determine if the narcotic log is incorrect
- C. Check with the last nurse to sign out narcotics from the system
- D. Notify the house supervisor that narcotic medications are missing
Correct Answer: A
Rationale: The correct answer is A: Perform the count again. The nurse should double-check the count to ensure accuracy before taking further action. Performing the count again helps to rule out any possible errors in the initial count. This step ensures that the discrepancy is not due to a simple mistake or oversight. Contacting the pharmacy (B), checking with the last nurse who signed out narcotics (C), or notifying the house supervisor (D) should be done after confirming the discrepancy through a recount. The first action should always be to verify the count internally before involving external parties or escalating the issue.