Nokea
Admission Assessment
Vital Signs
Nurses' Notes
82-year-old client admitted with nondisplaced hip fracture awaiting surgery. History of mild dementia, and hypotension. The family is concerned about malnutrition and living alone. The client's daughter who is the power of attorney (POA) is currently out of state.
A nurse is caring for a client who is exhibiting increased agitation. The nurse offered toileting, lowered the lights in the client's room and closed door to client's room. The nurse is at risk for which of the following as evidenced by applying wrist restraints to the client?
- A. False imprisonment
- B. Slander
- C. Negligence
- D. Battery
- E. Assault
Correct Answer: A
Rationale: [1, 0, 0, 0, 0]
Correct Answer: A
Rationale: Applying wrist restraints without appropriate justification can lead to false imprisonment, violating the client's rights. Slander (B) is verbal defamation; Negligence (C) is failure to provide reasonable care; Battery (D) is physical harm; Assault (E) is the threat of harm.
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A client who is terminally ill tells a nurse on the medical-surgical unit that she feels hopeless. Which of the following statements by the nurse is appropriate?
- A. I am sure these feelings will pass once you go home.
- B. Tell me what you understand about your illness.
- C. Tell me why you feel hopeless.
- D. If I were you, I would ask for a referral to hospice care.
Correct Answer: B
Rationale: The correct answer is B: "Tell me what you understand about your illness." This response shows active listening and encourages the client to express their thoughts and feelings, fostering trust and understanding. It allows the nurse to assess the client's knowledge and perception, helping tailor support accordingly. Choice A dismisses the client's feelings, lacking empathy. Choice C may come off as confrontational, potentially shutting down communication. Choice D imposes the nurse's opinion on the client. Choices E, F, and G are not applicable. In summary, choice B promotes therapeutic communication and client-centered care, while the other choices may hinder the nurse-client relationship.
A nurse is teaching a class on torts. The nurse should instruct the class that administering an antibiotic medication to a competent client after the client has refused it is an example of which of the following torts?
- A. False imprisonment
- B. Assault
- C. Battery
- D. Negligence
Correct Answer: C
Rationale: The correct answer is C: Battery. Battery is the intentional harmful or offensive touching of another person without consent. In this scenario, administering the antibiotic medication to a competent client after they have refused it constitutes a deliberate act of touching the client without their consent, which aligns with the definition of battery.
False imprisonment (A) involves restricting a person's freedom of movement unlawfully, which does not apply in this case. Assault (B) involves the threat of harmful or offensive contact, not the actual act itself. Negligence (D) is the failure to exercise proper care in a situation, which is not applicable here as the action was intentional.
A nurse in a provider's office is collecting a health history from a client who has a new prescription for glyburide to treat type 2 diabetes mellitus. Which of the following statements by the client indicates a contraindication for taking this medication?
- A. I had strep throat about one year ago.
- B. I got my flu shot at the pharmacy two weeks ago.
- C. I plan to continue nursing my baby until he is at least a year old.
- D. I am allergic to shellfish.
Correct Answer: C
Rationale: The correct answer is C. Glyburide is not recommended for use during breastfeeding as it can pass into breast milk and potentially harm the baby. Breastfeeding mothers should consult their healthcare provider for alternative medications. Choice A is unrelated, choice B and D are not contraindications for glyburide use.
A charge nurse hears a provider speaking to a staff nurse in anger concerning incorrect supplies that are available to perform a procedure. Which of the following statements by the charge nurse is appropriate?
- A. If you let us know ahead of time that you plan to perform a procedure, we could do better job of having the supplies available.
- B. It must be very frustrating when you don't have want you need to perform the procedure.
- C. I will help you with this procedure instead of the staff nurse.
- D. You should think about how you make others feel when you lose your temper.
Correct Answer: B
Rationale: The correct answer is B because it demonstrates empathy and understanding towards the staff nurse's frustration. By acknowledging the staff nurse's feelings and showing empathy, the charge nurse can diffuse the situation and work towards finding a solution collaboratively.
Choice A is not as appropriate because it may come across as blaming the staff nurse for the lack of supplies. Choice C is not ideal as it doesn't address the underlying issue of the incorrect supplies. Choice D shifts the focus away from the situation at hand and onto the provider's behavior.
In summary, choice B is the best response as it shows empathy, validates the staff nurse's feelings, and opens the door for constructive problem-solving.
A nurse is on the hospital quality and performance Improvement committee. The committee is reviewing compliance with prevention measures related to posterior cervical surgical site infections over the first 3 quarters of the year. Which measures should the nurse recognize that indicate the need for improvement compared to benchmarks? Select all that apply.
- A. Glucose control
- B. Intraoperative vancomycin
- C. Post operative normothermia
- D. Perioperative antibiotics
- E. Smoking cessation
Correct Answer: A,D,E
Rationale: The correct answers are A, D, and E. Glucose control, perioperative antibiotics, and smoking cessation are important prevention measures related to posterior cervical surgical site infections. Glucose control is crucial as hyperglycemia can impair immune function, leading to increased infection risk. Perioperative antibiotics help prevent surgical site infections by reducing bacterial load. Smoking cessation is vital as smoking impairs wound healing and increases infection risk. Intraoperative vancomycin (B) is not typically a prevention measure for surgical site infections in posterior cervical surgeries. Postoperative normothermia (C) is important for general patient care but is not specifically related to preventing surgical site infections in this context.