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A nurse enters a client's room and finds them on the floor. The client's roommate reports that the client was trying to get out of bed and fell over the side rail onto the floor. Which of the following statements should the nurse document about this incident?
- A. Incident report completed.
- B. Client climbed over the side rails.
- C. Client was trying to get out of bed.
- D. Client found lying on floor.
Correct Answer: C
Rationale: Rationale: The correct answer is C because it accurately describes the situation based on the information provided. Documenting that the client was trying to get out of bed aligns with the roommate's report of the incident. This statement is factual and relevant to the client's condition.
Summary:
A: Incident report completed - Not relevant to documenting the client's actions during the fall.
B: Client climbed over the side rails - Assumes an action not reported by the roommate.
D: Client found lying on floor - Describes the outcome, but does not explain the cause of the fall.
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The ANA is a registered labor organization, but it does not engage in direct __________.
- A. Empower union affiliation
- B. Reward union affiliation
- C. Encourage union affiliation
- D. Collective bargaining
Correct Answer: D
Rationale: The correct answer is D: Collective bargaining. The American Nurses Association (ANA) is a professional organization representing nurses, not a labor union. Therefore, it does not engage in direct collective bargaining on behalf of its members. Collective bargaining is the process of negotiation between employers and employees, typically labor unions, to determine wages, working conditions, and other terms of employment. The other choices (A, B, C) are incorrect because the ANA focuses on professional development, advocacy, and promoting the interests of nurses rather than traditional labor union activities like empowering, rewarding, or encouraging union affiliation.
Politics is a means for influencing events and the decisions of others. The nurse manager who consistently reminds the staff that 'there is no I in team' and periodically brings treats for the staff is using:
- A. Image enhancement
- B. Political skills
- C. Reward power
- D. Expert power
Correct Answer: B
Rationale: The correct answer is B: Political skills. The nurse manager is using political skills by emphasizing teamwork and building relationships through treats to influence the staff. This demonstrates an understanding of social dynamics and power structures within the team. Image enhancement (A) focuses on improving one's personal or professional reputation, not team dynamics. Reward power (C) involves using rewards or incentives to influence behavior, which is not the case here. Expert power (D) is based on knowledge and expertise, but the scenario does not indicate that the nurse manager is leveraging expertise to influence the team.
Which of the following best describes the concept of cultural humility in nursing?
- A. A fixed set of cultural competencies
- B. Recognizing and addressing power imbalances
- C. Adapting care to fit different cultural contexts
- D. Learning from patients and adapting to their needs
Correct Answer: D
Rationale: The correct answer is D because cultural humility in nursing emphasizes continuous learning from patients and adapting care based on their individual needs. This approach values patient input and focuses on building mutual respect and trust. Choice A is incorrect because cultural humility is not about a fixed set of competencies but rather an ongoing process. Choice B is incorrect as it only addresses one aspect of cultural humility related to power dynamics. Choice C is incorrect as it focuses on adapting care to fit different cultural contexts rather than individual patient needs. In summary, cultural humility in nursing involves actively listening, learning, and adapting to meet the unique needs of each patient.
The nurse is interviewing a new patient with diabetes who receives rosiglitazone (Avandia)
through a restricted access medication program. What is most important for the nurse to report
immediately to the health care provider?
- A. The patient's blood pressure is 154/92.
- B. The patient has a history of emphysema
- C. The patient's blood glucose is 86 mg/dL.
- D. The patient has chest pressure when walking
Correct Answer: D
Rationale: The correct answer is D: The patient has chest pressure when walking. This symptom could indicate cardiac issues, a known side effect of rosiglitazone. Reporting this immediately is crucial to prevent potential serious complications.
A: The patient's blood pressure is 154/92. While high, it is not an immediate concern unless accompanied by other symptoms.
B: The patient has a history of emphysema. Relevant but not urgent in this scenario.
C: The patient's blood glucose is 86 mg/dL. Within the normal range and not a priority compared to chest pressure.
In summary, choice D is correct as it addresses a potentially severe side effect of the medication that requires immediate attention. Choices A, B, and C are not as urgent or directly related to the medication's side effects.
What is the primary role of the nurse manager in risk management?
- A. Ensure compliance with regulations
- B. Report incidents to higher authorities
- C. Minimize risks to patients and staff
- D. Educate staff about safe practices
Correct Answer: C
Rationale: The primary role of the nurse manager in risk management is to minimize risks to patients and staff. This involves identifying potential risks, implementing strategies to prevent harm, and ensuring a safe environment. By minimizing risks, the nurse manager promotes patient safety and staff well-being.
A: Ensuring compliance with regulations is important but not the primary role of the nurse manager in risk management.
B: Reporting incidents to higher authorities is a part of risk management, but not the primary role of the nurse manager.
D: Educating staff about safe practices is crucial in risk management, but the primary role of the nurse manager is to minimize risks directly.