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A health care provider writes these new prescriptions for a resident in a skilled nursing facility: 2G sodium diet, Restraint as needed, Limit fluids to 1800~mL daily, Continue antihypertensive medication, Milk of magnesia 30~mL PO once if no bowel movement for 3 days. The nurse should:
- A. question the fluid restriction
- B. question the order for restraint
- C. transcribe the prescriptions as written
- D. assess the residents bowel elimination
Correct Answer: B
Rationale: Restraints may be imposed only on a written order of the health care provider that specifies the duration during which the restraints can be used. The Joint Commission guidelines and Omnibus Budget Reconciliation Act regulations also mandate a number of other conditions that must be considered and documented before restraints are used. The other prescriptions are appropriate.
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A person who was raped comes to the hospital for treatment. The person abruptly decides to decline treatment and leave the facility. Before this person leaves, the nurse should:
- A. Say, "You may not leave until you're given prophylactic treatment for sexually transmitted diseases."Â
- B. Provide written information about physical and emotional reactions the person may experience.
- C. Explain the need and importance of HIV and pregnancy tests.
- D. Give verbal information about legal resources.
Correct Answer: B
Rationale: The correct answer is B because providing written information about physical and emotional reactions respects the individual's autonomy and empowers them to make informed decisions. It also ensures they have resources to understand and cope with potential consequences. Choice A violates the individual's right to refuse treatment. Choice C focuses on specific tests without addressing the person's immediate concerns. Choice D, while important, is not as immediate or relevant as providing information on potential reactions.
An emergency department nurse prepares to assist with evidence collection for a sexual assault victim. Prior to photographs and pelvic examination, what documentation is important?
- A. The patient's vital signs
- B. Consent signed by the patient
- C. Supervision and credentials of the examiner
- D. Storage location of the patient's personal effects
Correct Answer: B
Rationale: The correct answer is B: Consent signed by the patient. This is crucial as it ensures the patient's autonomy and willingness to undergo evidence collection. Without proper consent, the procedure would be unethical and potentially illegal. Vital signs (A) may be important for overall assessment but are not directly related to evidence collection. Supervision and credentials of the examiner (C) are necessary but not the most important documentation. The storage location of personal effects (D) is relevant for patient safety but not essential for evidence collection.
Features of schizoid personality include.
- A. Hyper-vigilant ready for real or imagines threat
- B. Inability to respond to others, hyper-vigilant
- C. Social withdrawal, inability to respond to others
- D. Ready for real or imagined threat, social withdrawal
Correct Answer: C
Rationale: Schizoid personality disorder is characterized by social withdrawal and emotional detachment, with little interest in relationships.
The patient on the mental health unit who should be assessed as being at highest risk for directing violent behavior toward others is the patient who has:
- A. Obsessive-compulsive disorder and performs many rituals.
- B. Paranoid delusions of being followed by the Mafia.
- C. Severe depression with feelings of worthlessness and self-loathing.
- D. Completed alcohol withdrawal and is now in a rehabilitation program.
Correct Answer: B
Rationale: The correct answer is B because paranoid delusions of being followed by the Mafia indicate a high level of suspiciousness and potential for harm to others. This patient may act out violently in self-defense or as a reaction to perceived threats. Choice A is incorrect as OCD rituals are typically not associated with violent behavior. Choice C is incorrect as severe depression is more likely to result in self-harm rather than harm towards others. Choice D is incorrect as completed alcohol withdrawal and entering a rehabilitation program do not inherently indicate an increased risk of violent behavior towards others.
The nurse who is caring for a 23-year-old client with bulimia knows that the most common method of purging to monitor this client for is:
- A. Vomiting.
- B. Starvation.
- C. Excessive enema use.
- D. None of the above.
Correct Answer: A
Rationale: The correct answer is A: Vomiting. In bulimia, vomiting is the most common method of purging after binge eating to control weight. Monitoring for signs of vomiting, such as frequent trips to the bathroom after meals or presence of swollen salivary glands, is crucial. Starvation (B) is not a method of purging in bulimia but rather a consequence of restriction in anorexia nervosa. Excessive enema use (C) is not a common method of purging in bulimia and can be harmful. Therefore, the correct choice is A as it aligns with the typical behavior of individuals with bulimia.