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A friend of the parents of a newborn with a diagnosis of congenital tracheoesophageal fistula contacts the home health nurse with an offer to help. Which is the best nursing action at this time to address the needs and rights of the family?
- A. Inform the friend to directly contact the family and offer assistance to them.
- B. Request that the friend come to the client's home during the next home health visit.
- C. Report the friend's call to the nurse manager for referral to the client's social worker.
- D. Assure the friend that there is no need for assistance since the nurse is visiting daily.
Correct Answer: A
Rationale: The nurse must uphold the client's rights and does not give any information regarding a client's care needs to anyone who is not directly involved in the client's care. To request that the friend come for teaching is a direct violation of the client's right to privacy. There is no information in the question to indicate that the family desires assistance from the friend. To refer the call to the nurse manager and social worker again assumes that the friend's assistance and involvement are desired by the family. Informing the friend that the nurse is visiting daily is providing information that is considered confidential. Option 1 directly refers the friend to the family.
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Which scenarios demonstrate a participative style of leadership? Select all that apply.
- A. The nurse manager presents a problem to the staff and tells the staff to solve the problem.
- B. The nurse manager arranges unit meetings for all shifts to deal with an identified problem.
- C. The nurse manager assesses a problem and informs the staff of the solution to be implemented.
- D. The nurse manager proposes several methods of dealing with a problem and invites team input.
- E. The nurse manager proposes several solutions to a problem and has the unit staff vote on the best option.
- F. The nurse manager considers staff input related to a problem but makes the final decision on implementation of the solution.
Correct Answer: B,D,F
Rationale: Participative leadership demonstrates an 'in-between' style, neither authoritarian nor democratic. In participative leadership, the manager presents an analysis of problems and proposals for actions to team members, inviting critique and comments. The participative leader then analyzes the comments and makes the final decision. The autocratic style of leadership is task oriented and directive. A laissez-faire leader abdicates leadership and responsibilities, allowing staff to work without assistance, direction, or supervision. The democratic style of leadership involves a majority rule.
When planning the discharge of a client with a diagnosis of chronic anxiety, the nurse develops goals to promote a safe environment at home. Which topic is an appropriate maintenance goal for the client to focus on?
- A. Identifying anxiety-producing situations
- B. Maintaining contact with a crisis counselor
- C. Techniques for ignoring feelings of anxiety
- D. Eliminating all anxiety from daily situations
Correct Answer: A
Rationale: Recognizing situations that produce anxiety allows the client to prepare to cope with anxiety or avoid a specific stimulus. Counselors will not be available for all anxiety-producing situations. Additionally, this option does not encourage the development of internal strengths. Ignoring feelings will not resolve anxiety. It is impossible to eliminate all anxiety from life.
The nurse has a prescription to get the client out of bed to a chair on the first postoperative day after total knee replacement surgery. Which action is most appropriate for the nurse to plan to implement to protect the knee joint?
- A. Applying both ice and a compression dressing to the knee while sitting.
- B. Obtaining a walker to minimize weight-bearing by the client on the affected leg.
- C. First applying a knee immobilizer and then elevating the affect leg while sitting.
- D. Lifting the client to the bedside chair, leaving the continuous passive motion (CPM) machine in place.
Correct Answer: C
Rationale: After a total knee replacement, as prescribed, the nurse assists the client to get out of bed on the first postoperative day after putting a knee immobilizer on the affected joint to provide stability. The leg is elevated while the client is sitting in the chair to minimize edema. A compression dressing should already be in place on the wound. Ice is not used unless prescribed. The surgeon prescribes the weight-bearing limits on the affected leg. A CPM machine is used only while the client is in bed and is initiated when prescribed.
The nurse manager is observing the interaction between a new staff nurse and a client currently receiving hemodialysis. Which intervention should the nurse manager implement when the nurse and client are both drinking coffee and discussing the client's feeling about the procedure?
- A. Getting a cup of coffee and join in on the conversation
- B. Determining whether or not the client should be drinking coffee
- C. Complementing the staff nurse on the development of a good therapeutic relation
- D. Asking the staff nurse to refrain from eating and drinking in the hemodialysis area
Correct Answer: D
Rationale: The nurse manager should ask the second nurse to stop eating and drinking in the client area. A potential complication of hemodialysis is the acquisition of dialysis-associated hepatitis B. This is a concern for clients (who may carry the virus), client families (at risk from contact with the client and with environmental surfaces), and staff (who may acquire the virus from contact with the client's blood). This risk is minimized by the use of standard precautions; appropriate hand-washing and sterilization procedures; and the prohibition of eating, drinking, or other hand-to-mouth activity in the hemodialysis unit. None of the remaining options relate to management of this potential complication.
A client has a prescription for valproic acid 250 mg once daily. To maximize the client's safety, which time is best for the nurse to schedule administration of the medication?
- A. With lunch
- B. With breakfast
- C. Before breakfast
- D. At bedtime with a snack
Correct Answer: D
Rationale: Valproic acid is an anticonvulsant that causes central nervous system (CNS) depression. For this reason, the side and adverse effects include sedation, dizziness, ataxia, and confusion. When the client is taking this medication as a single daily dose, administering it at bedtime negates the risk of injury from sedation and enhances client safety. Otherwise, it may be given after meals to avoid gastrointestinal upset.