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A nurse is assisting with the care of a group of clients during a mass casualty event. Which of the following tasks should the nurse assign to an assistive personnel (AP)?
- A. Respond to family members about a client's condition.
- B. Determine which clients should be seen first.
- C. Clean and dress client abdominal wounds.
- D. Take vital signs on clients as they are admitted.
Correct Answer: D
Rationale: Taking vital signs is within the AP's scope, unlike triage or wound care.
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A nurse is collecting data from a toddler during a well-child visit. Which of the following actions should the nurse take to prepare the toddler for a physical examination?
- A. Thoroughly explain each procedure to the toddler.
- B. Start the examination with routine immunizations.
- C. Allow the toddler to handle the equipment.
- D. Completely undress the toddler.
Correct Answer: C
Rationale: Allowing the toddler to handle equipment reduces fear and increases cooperation.
The client is experiencing delirium.
A nurse is collecting data from a client who is experiencing delirium. Which of the following findings should the nurse expect?
- A. Echopraxia
- B. Aphasia
- C. Acute onset of confusion
- D. Inability to read
Correct Answer: C
Rationale: Acute onset of confusion is a hallmark of delirium.
While reinforcing teaching about the client's prescribed medications, the nurse communicates truthfully about the adverse effects of the medications.
A nurse is caring for a client who has been admitted to the mental health unit. While reinforcing teaching about the client's prescribed medications, the nurse communicates truthfully about the adverse effects of the medications. Which of the following ethical concepts is the nurse exhibiting?
- A. Autonomy
- B. Justice
- C. Veracity
- D. Beneficence
Correct Answer: C
Rationale: Veracity reflects truthfulness, as the nurse honestly discusses medication adverse effects.
The client has a history of hypertension.
A nurse is caring for a client who has a history of hypertension. Which of the following findings should the nurse recognize is indicative of transient ischemic attacks?
- A. Epigastric pain
- B. Seizure activity
- C. Sudden loss of vision in one eye
- D. Pain radiating down the left arm
Correct Answer: C
Rationale: Sudden monocular vision loss is a classic TIA symptom.
A nurse is caring for a client who has dementia. Which of the following findings should the nurse expect?
- A. Memory loss that disrupts ADLs
- B. Acute onset of confusion
- C. Illusions
- D. Catatonia
Correct Answer: A
Rationale: Memory loss disrupting ADLs is a hallmark of dementia.