Nokea
A client jumped out of a window on the second floor of the hospital and sustained a spinal cord injury that resulted in the inability to have upper and lower extremity sensation. What type of documentation by the nurse would be appropriate in this situation?
- A. The client must have been depressed and wanted to commit suicide.'
- B. I saw the client get ready to jump and was unable to get to them fast enough.'
- C. Client observed standing on the window ledge; asked client to come down and proceeded to enter the room, and client jumped through the glass.'
- D. The previous shift should have notified the physician that the client was suicidal.'
Correct Answer: C
Rationale: The documentation in which the nurse describes observing the client on the window ledge, asking the client to come down and entering the room, and the client jumping through the class is objective, accurate, and concise. The other choices were judgmental, subjective, and vague.
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Which type of law concerns offenses that violate the public's welfare?
- A. Statutory law
- B. Common law
- C. Administrative law
- D. Criminal law
Correct Answer: D
Rationale: Criminal law concerns offenses that violate the public's welfare. Statutory law is law that any local, state, or federal legislative body enacts. Common is based on earlier court decisions, judgment, and decrees. Administrative law means that regulatory agencies enforce the rules and regulations that concern health, welfare, and safety of federal and state citizens.
The LPN administered a medication to a client reporting pain. When checking the armband and the medication administration record, there were no allergies listed. The client then tells the nurse of having informed the admitting nurse of being allergic to that medication. What documentation on the incident form would be the best option?
- A. Medication is administered to client by mouth; reports having an allergy to the medication that causes hives.'
- B. The admitting nurse failed to document that the client has an allergy to the medication.'
- C. The client reports being allergic to the medication, but I really don't think so. I didn't see any hives.'
- D. I should have asked the RN if the client is allergic to any medication.'
Correct Answer: A
Rationale: Healthcare workers complete incident reports when they make or discover errors or when an event occurs that results in harm. The first option is concise and to the point without any accusation. The LPN's documentation should not accuse the admitting nurse of failure to document. The LPN's documentation should not judge the client's statement nor place blame on the client. The LPN's documentation also should not place the blame on oneself.
Which of the following is stated in a living will?
- A. Legal consent regarding healthcare
- B. Designation of another person as healthcare proxy
- C. Wishes regarding healthcare if terminally ill
- D. Medical prescriptions for end-of-life instructions
Correct Answer: C
Rationale: A living will is a document that states a client's wishes regarding healthcare if the client is terminally ill. It is not necessarily a legal consent. A client may designate another person to be the medical durable power of attorney or healthcare proxy. Do-not-resuscitate orders contain written medical prescriptions for end-of-life instructions.
The nurse is caring for a client who has been intubated and on a mechanical ventilator and has been restrained with soft wrist restraints. The client no longer requires the restraints, so the nurse removes them. What type of ethical decision making does the nurse display?
- A. Fidelity
- B. Autonomy
- C. Beneficence
- D. Nonmaleficence
Correct Answer: C
Rationale: Beneficence is the duty to do good for the clients assigned to the nurse's care. The nurse has a duty to remove wrist restraints whenever possible (removing a harm) and to help the client regain independence (promoting and doing good). Fidelity is the duty to maintain commitments of professional obligations and responsibilities. Autonomy refers to a client's right to self-determination or the freedom to make choices without opposition. Nonmaleficence is the duty to do no harm to the client.
Which of the following statements regarding the statute of limitations is correct?
- A. It is applicable only in the case of a minor.
- B. There is no designated time for a person to file a lawsuit.
- C. The designated time is typically calculated from the time the incident occurred.
- D. It provides legal immunity to rescuers who provide first aid in the case of an emergency.
Correct Answer: C
Rationale: A statute of limitations is the designated time for a person to file a lawsuit. The time is typically calculated from the time the incident occurred. If the injured party is a minor, the statute of limitations sometimes does not commence until the victim reaches adulthood. Good Samaritan law ensures legal immunity for rescuers who provide first aid in the case of an emergency to accident victims.