Nokea
A client tells the nurse, "I have something very important to tell you if you promise not to tell." The best response by the nurse is
- A. I must document and report any information.
- B. I can't make such a promise.
- C. That depends on what you tell me.
- D. I must report everything to the treatment team.
Correct Answer: B
Rationale: Secrets are inappropriate in therapeutic relationships and are counter productive to the therapeutic efforts of the interdisciplinary team. Secrets may be related to risk for harm to self or others. The nurse honors and helps clients to understand rights, limitations, and boundaries regarding confidentiality.
You may also like to solve these questions
When assessing a client, it is important for the nurse to be informed about cultural issues related to the client's background because
- A. normal patterns of behavior may be labeled as deviant, immoral, or insane
- B. the meaning of the client's behavior can be derived from conventional wisdom
- C. personal values will guide the interaction between persons from 2 cultures
- D. the nurse should rely on her knowledge of different developmental mental stages
Correct Answer: A
Rationale: Normal patterns of behavior may be labeled as deviant, immoral, or insane. Culture is an important variable in the assessment of individuals. To work effectively with clients, the nurse must be aware of a cultural distinctive qualities.
The expectant mother asks the nurse, "With all the babies in the nursery, how will I know that the nurse is bringing rue my baby?" What is the nurse's best response?
- A. "The baby has a plastic bracelet with permanent locks that must be cut for removal."
- B. "If taken from the unit, your baby's security band will set off an alarm and lock exits."
- C. "Your identification number and full name are printed on your baby's identification band."
- D. "An identification band is applied to your infant, and footprints are taken and kept on record."
Correct Answer: C
Rationale: Matching identification numbers and the mother's full name on the infant's band ensures accurate identification, which is the primary method.
Which of these clients would the nurse recommend keeping in the hospital during an internal disaster at that facility?
- A. An adolescent diagnosed with sepsis 7 days ago and whose vital signs are maintained within low normal limits.
- B. A middle-aged woman known to have had an uncomplicated myocardial infarction 4 days ago
- C. An elderly man admitted 2 days ago with an acute exacerbation of ulcerative colitis
- D. A young adult in the second day of treatment for an overdose of acetaminophen
Correct Answer: D
Rationale: A young adult in the second day of treatment for an overdose of acetaminophen. An overdose of Tylenol requires close observation for 3 to 4 days as well as Mucomyst PO during that time. A strong risk of liver failure exists immediately following Tylenol overdose.
A nurse working in a pediatric clinic observes bruises on the body of a four year-old boy. The parents report the boy fell riding his bike. The bruises are located on his posterior chest wall and gluteal region. The nurse should:
- A. Suggest a script for counseling for the family to the doctor on duty.
- B. Recommend a warm bath for the boy to decrease healing time.
- C. Notify the case manager in the clinic about possible child abuse concerns.
- D. Recommend ROM to the patient's spine to decrease healing time.
Correct Answer: C
Rationale: The patient's safety should have the highest priority.
Which of these instructions should the nurse include when preparing a client for a radioactive iodine (I-131) uptake test and treatment for hyperthyroidism?
- A. Avoid taking aspirin for 3 days prior to the test.'
- B. You may eat a light breakfast on the morning of the test.'
- C. Expect to stay in the hospital for 24 hours after treatment.'
- D. In the initial 48 hours, avoid contact with children and pregnant women, and flush the commode twice after urination or defecation.'
Correct Answer: A
Rationale: In the initial 48 hours, avoid contact with children and pregnant women, and flush the commode twice after urination or defecation. The client's urine and saliva are radioactive for 24 hours after ingestion, and vomitus is radioactive for 6 to 8 hours.