Nokea
A nurse in an emergency department completes an assessment on an adolescent client with conduct disorder. The client threatened suicide to a teacher at school. Which of the following statements should the nurse include in the assessment?
- A. Tell me about your siblings
- B. Tell me what kind of music you like
- C. Tell me how often you drink alcohol
- D. Tell me about your school schedule
Correct Answer: C
Rationale: The correct answer is C: 'Tell me how often you drink alcohol.' Alcohol use can exacerbate aggressive behaviors and is relevant for the assessment of suicide risk in adolescents with conduct disorders. Choices A, B, and D are unrelated to the assessment of suicide risk in this scenario and do not provide information that directly impacts the client's risk assessment.
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A nurse is performing a dressing change for a client who has a sacral wound using negative pressure wound therapy. Which of the following actions should the nurse take first?
- A. Apply skin preparation to wound edges
- B. Cleanse the wound with normal saline
- C. Don sterile gloves
- D. Determine the client's pain level
Correct Answer: D
Rationale: The correct answer is to determine the client's pain level first. Assessing the client's pain is crucial before proceeding with any procedure, including dressing changes. This step ensures that appropriate pain management measures can be implemented, making the wound care process as comfortable as possible for the patient. Applying skin preparation to wound edges (choice A) can come after addressing the pain. While cleansing the wound with normal saline (choice B) and donning sterile gloves (choice C) are important steps in wound care, they should follow the assessment of the client's pain level to prioritize the patient's comfort and well-being.
A nurse is planning care for a client who has a sealed radiation implant and is to remain in the hospital for one week. Which of the following should the nurse include in the plan of care?
- A. Remove dirty linens from the room after double-bagging them
- B. Wear a dosimeter film badge while in the client's room
- C. Limit each visitor to one hour per day
- D. Ensure family members remain at least 3 feet from the client
Correct Answer: B
Rationale: The correct answer is to wear a dosimeter film badge while in the client's room. Wearing a dosimeter helps monitor the cumulative radiation exposure of healthcare workers, ensuring their safety during care. Removing dirty linens, limiting visitor time, and maintaining a distance from the client are not directly related to radiation safety measures and are not necessary in this scenario.
During a change-of-shift assessment, a nurse is evaluating four clients. Which finding should the nurse report to the provider first?
- A. Client with cystic fibrosis who has a thick productive cough and reports thirst
- B. Client with gastroenteritis who is lethargic and confused
- C. Client with diabetes mellitus who has a morning fasting glucose of 185 mg/dL
- D. Client with sickle cell anemia who reports pain 15 minutes after receiving analgesic
Correct Answer: B
Rationale: The nurse should report the client with gastroenteritis who is lethargic and confused to the provider first. Lethargy and confusion in a client with gastroenteritis may indicate dehydration or electrolyte imbalance, both of which can be life-threatening if not addressed promptly. The other options indicate important assessments that require intervention but do not pose an immediate life-threatening risk compared to the client with signs of dehydration and electrolyte imbalance.
A client wearing an arm cast reports numb fingers. Which of the following actions should the nurse take first?
- A. Place the arm in a dependent position
- B. Administer pain medication
- C. Check the client's circulation
- D. Apply a warm compress to the fingers
Correct Answer: C
Rationale: The correct answer is to check the client's circulation. Numbness in the fingers may indicate compromised circulation or nerve damage. By assessing the circulation first, the nurse can ensure that the cast is not too tight, which could be cutting off blood flow. Option A is incorrect because placing the arm in a dependent position may worsen circulation issues. Option B is incorrect as administering pain medication does not address the underlying cause of numbness. Option D is incorrect as applying a warm compress could mask circulation issues and is not the priority in this situation.
A nurse is caring for a client who repeatedly refuses meals. The nurse overhears an assistive personnel telling the client, "If you don't eat, I'll put restraints on your wrists and feed you." The nurse should intervene and explain to the AP that this statement constitutes which of the following torts?
- A. Assault
- B. Battery
- C. Malpractice
- D. Negligence
Correct Answer: A
Rationale: The correct answer is A: Assault. Assault is the act of threatening a client with harm, such as the threat of using restraints to force-feed the client, even if no physical contact occurs. In this scenario, the statement made by the assistive personnel constitutes assault because it involves the threat of harm. Choice B, Battery, involves actual physical contact without the client's consent, which is not present in the scenario. Choice C, Malpractice, refers to professional negligence or misconduct, not a direct threat to the client. Choice D, Negligence, involves failure to provide reasonable care that results in harm, which is not applicable in this context.