Nokea
A home health nurse is planning care for a client who has Alzheimer's disease. The client's partner is her primary caregiver and reports not having enough time to complete his errands. Which of the following referrals should the nurse plan to make?
- A. Respite care
- B. Restorative care
- C. Hospice care
- D. Mental health care
Correct Answer: A
Rationale: The correct answer is A: Respite care. This is the most appropriate referral for the client's partner who needs time off from caregiving responsibilities to complete errands. Respite care provides temporary relief for the primary caregiver, allowing them to take a break while ensuring the client's needs are still met. This helps prevent caregiver burnout and promotes overall well-being for both the caregiver and the client.
Choices B, C, and D are incorrect:
B: Restorative care focuses on restoring the client's functional abilities and independence, which is not directly related to the partner's need for time off.
C: Hospice care is for clients with terminal illnesses who are no longer receiving curative treatment, which is not applicable in this scenario.
D: Mental health care may be beneficial for the client or caregiver in managing emotions and stress, but it does not address the immediate need for respite care.
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An assistive personnel (AP) comes to work with a new set of artificial nails. The nurse takes the AP to a private location to discuss the issue. Which of the following statements by the nurse is appropriate?
- A. I want you to review the facility's policy on personal attire before you begin the shift.
- B. There is a higher risk of infection for our clients associated with artificial nails.
- C. Why would you wear artificial nails to work when you know it's against the rules?
- D. You should know that artificial nails have a very unprofessional appearance.
Correct Answer: B
Rationale: The correct answer is B: There is a higher risk of infection for our clients associated with artificial nails. This statement is appropriate because it directly addresses the potential harm that the AP's artificial nails could pose to clients. Artificial nails can harbor bacteria and increase the risk of transmitting infections in a healthcare setting. It focuses on the importance of infection control and patient safety.
Other choices are incorrect:
A: While reviewing facility policy is important, it does not directly address the issue of infection risk.
C: This statement is accusatory and does not promote a constructive dialogue about infection control.
D: Commenting on appearance is not relevant to the infection risk associated with artificial nails.
A nurse is triaging clients in the emergency department. Which of the following clients should the nurse ask the provider to care for first?
- A. A toddler who has asthma and has a pulse oximetry reading of 95% while receiving oxygen at 2 L/min
- B. An adolescent who has sickle cell disease, reports pain as 7 on a scale of 0 to 10, and requests pain medication
- C. A toddler who has otitis media, a temperature of 39.2 C (102.6° F), and purulent ear discharge
- D. A school-age child who has acute epiglottitis, is drooling, and has an absence of spontaneous cough
Correct Answer: D
Rationale: The correct answer is D. Acute epiglottitis is a medical emergency due to potential airway compromise. The child's drooling and absence of cough indicate a severe obstruction that can rapidly progress to complete airway closure. Immediate intervention is crucial to prevent respiratory distress or arrest. Choices A, B, and C have less urgent conditions that can be managed after ensuring the child with epiglottitis receives prompt care. Choice A, although having asthma, is stable with adequate oxygenation. Choice B, although in pain, can wait briefly for pain medication. Choice C, although having otitis media, does not present immediate life-threatening risk compared to epiglottitis.
A nurse manager has recently become aware of a conflict between the pharmacy and the staff nurses regarding sending and receiving medications. Which of the following actions should the nurse take first to resolve the conflict?
- A. Evaluate the results.
- B. Brainstorm solutions.
- C. Implement a resolution.
- D. Identify the problem
Correct Answer: D
Rationale: The correct answer is D: Identify the problem. This is the first step in conflict resolution as it allows the nurse manager to understand the root cause of the conflict between pharmacy and staff nurses. By identifying the problem, the nurse manager can gather relevant information, perspectives, and concerns from both parties. This step is crucial in developing an effective resolution strategy.
Choice A (Evaluate the results) is incorrect as evaluation should come after identifying the problem. Choice B (Brainstorm solutions) is premature without understanding the underlying issue. Choice C (Implement a resolution) should not be done before identifying the problem to ensure the solution addresses the actual conflict.
A charge nurse is reviewing the documentation of a newly licensed nurse. Which of the following entries requires follow-up?
- A. Client received 2 mg morphine IV at 0900 for pain rated 6/10.
- B. Client's blood pressure is normal after medication administration.
- C. Client refused morning medications; provider notified.
- D. Client's wound dressing changed at 1100 per protocol.
Correct Answer: B
Rationale: Describing blood pressure as 'normal' is vague and lacks specific data, requiring follow-up to ensure accurate and complete documentation.
A nurse is caring for a client who is confused and uncooperative. The client hit the nurse when she attempted to give him his medication. The nurse asks the charge nurse if she can restrain the client. The charge nurse should tell the nurse this action is a violation of the client's rights and is an example of which of the following?
- A. Defamation of character
- B. Slander
- C. False imprisonment
- D. Invasion of privacy
Correct Answer: C
Rationale: Correct Answer: C. False imprisonment
Rationale:
1. False imprisonment is the intentional restriction of a person's freedom of movement without justification.
2. Restraining the client against their will without a valid reason is a violation of their rights.
3. The client has the right to refuse treatment, and restraining them would be considered false imprisonment.
4. Defamation of character (A) and slander (B) involve damaging one's reputation through false statements.
5. Invasion of privacy (D) pertains to intrusion into a person's private affairs, not physical restraint.