Nokea
A nurse is assessing an older adult client who was brought to the emergency department by his son, who reports that the client fell at home. The nurse suspects elder abuse. Which of the following actions should the nurse take?
- A. File an incident report.
- B. Ask the client about his injuries with the son present.
- C. Ask the client's son to go to the waiting area.
- D. Treat and discharge the client
Correct Answer: C
Rationale: The correct action for the nurse to take is to ask the client's son to go to the waiting area. This allows the nurse to interview the client independently to assess for signs of elder abuse without the son's potential influence. Filing an incident report may be necessary later but is not the immediate action required. Asking about injuries with the son present could lead to biased responses or intimidation. Treating and discharging the client without addressing the suspicion of elder abuse would neglect the nurse's responsibility to ensure the client's safety.
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A nurse is caring for a client who wanders through the halls yelling obscenities at staff, other clients, and visitors. Which of the following actions should the nurse take?
- A. Keep the client in their room with the door closed
- B. Contact a family member to come and sit with the client
- C. Place the client in a wheelchair with a lap tray
- D. Administer a sedative to the client
Correct Answer: B
Rationale: When dealing with a client exhibiting disruptive behavior like yelling obscenities, involving a family member can provide emotional support and help in de-escalating the situation. Keeping the client isolated in their room (Choice A) may lead to further agitation. Placing the client in a wheelchair (Choice C) or administering a sedative (Choice D) should not be the first interventions for managing behavioral issues.
A charge nurse notices that two staff nurses are not taking meal breaks during their shifts. Which of the following actions should the nurse take first?
- A. Discuss time management strategies with the nurses
- B. Provide coverage for the nurses' breaks
- C. Determine the reasons the nurses are not taking scheduled breaks
- D. Review policies for taking scheduled breaks
Correct Answer: C
Rationale: The correct answer is to determine the reasons the nurses are not taking scheduled breaks. This action is crucial as it allows the charge nurse to understand the underlying causes for the behavior. By identifying the reasons, the nurse can then address the root of the issue effectively. Option A is incorrect because discussing time management strategies may not address the specific reasons for not taking breaks. Option B is incorrect as providing coverage for breaks does not address the underlying cause of the issue. Option D is also incorrect as reviewing policies should come after understanding the reasons for the behavior.
Which manifestation should the nurse expect to assess in a patient with fluid volume deficit?
- A. Headache and muscle cramps
- B. Dyspnea and respiratory crackles
- C. Increased pulse rate and blood pressure
- D. Orthostatic hypotension and flat neck veins
Correct Answer: D
Rationale: Orthostatic hypotension and flat neck veins are classic manifestations of fluid volume deficit. When the body loses fluid, blood volume decreases, leading to decreased venous return to the heart, resulting in orthostatic hypotension and flat neck veins. Choices A, B, and C are more indicative of other conditions such as dehydration, respiratory issues, or compensatory mechanisms in response to hypovolemia, respectively.
Which of the following most accurately describes a current concern in health care today?
- A. Health care-associated (nosocomial) infections continue to increase, not limited to health-care settings.
- B. Despite preventable deaths increasing from the opioid crisis, life expectancy in the United States has slightly risen over the last 2 years.
- C. Although adverse drug events persist, medication errors have not been completely eliminated through the use of electronic medication administration records.
- D. Gun violence has become a growing public health concern.
Correct Answer: D
Rationale: Gun violence has become a growing public health concern due to the increasing rates of injury and death caused by the misuse of firearms. Choice A is incorrect because health care-associated infections are not limited to health-care settings and continue to increase. Choice B is inaccurate as preventable deaths from the opioid crisis have not led to a rise in life expectancy in the United States. Choice C is incorrect as medication errors have not been completely eliminated despite the use of electronic medication administration records.
Marlisa has been diagnosed with diabetes mellitus type 1. She asks Nurse Errol what this means. What is the best response by the nurse? Select the one that does not apply.
- A. Your beta cells should be able to secrete insulin, but cannot.
- B. The endocrine function of your pancreas is to secrete insulin.
- C. Without insulin, you will develop ketoacidosis (DKA).
- D. The exocrine function of your pancreas is to secrete Estrogen.
Correct Answer: D
Rationale: Type 1 diabetes is characterized by the inability of the beta cells in the pancreas to secrete insulin. Choice A is correct because it highlights the role of beta cells. Choice B is accurate as the endocrine function of the pancreas includes insulin secretion. Choice C is true as without insulin, ketoacidosis can develop. Choice D is incorrect as the exocrine function of the pancreas involves secreting digestive enzymes, not estrogen.