Nokea
A nurse is preparing to administer an as-needed (PRN) medication. Which of the following would the nurse need to keep in mind when documenting administration?
- A. It requires a separate entry that includes reason for administration, dosage, route, and response to the medication the first time it is administered to a patient.
- B. It requires a separate entry that includes reason for administration, dosage, route, and response to the medication every time it is administered to a patient.
- C. It requires a separate entry that includes reason for administration, dosage, and route the first time it is administered to a patient.
- D. It requires a separate entry that includes reason for administration, dosage, and route every time it is administered to a patient.
Correct Answer: B
Rationale: PRN medication administration requires documentation each time, including the reason, dosage, route, and patient response, to ensure accurate tracking of treatment and outcomes.
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A nurse is caring for a patient who is hospitalized for a mental disorder. The nurse is legally obligated to breach the patient?s confidentiality if the patient states which of the following?
- A. I think that the federal government is spying on me.
- B. I get really ?turned on? by your appearance.
- C. That doctor I had today really made me angry.
- D. When I get out of here, I?m going to kill my neighbor.
Correct Answer: D
Rationale: Nurses are legally obligated to breach confidentiality when there is a credible threat of harm to others, such as a statement of intent to kill someone, under the duty to warn (Tarasoff principle).
A patient is involuntarily committed without a court order. The nurse understands that the emergency short-term hospitalization can occur for which time frame?
- A. A maximum of 24 hours
- B. 48 to 92 hours
- C. 3 to 5 days
- D. One week
Correct Answer: B
Rationale: Emergency short-term involuntary hospitalization, often under a psychiatric hold, typically lasts 48 to 72 hours (up to 92 hours in some jurisdictions) for evaluation, pending a court hearing.
Which patient would the nurse determine to be the most likely a candidate for involuntary commitment?
- A. The client who refuses to take the prescribed medication
- B. The client who is screaming in the street disturbing neighbors
- C. The client who refuses to participate in the planned therapy
- D. The client with a mental disorder who is homeless
Correct Answer: B
Rationale: Involuntary commitment is warranted when a patient poses a danger to themselves or others or is gravely disabled due to mental illness. Screaming in the street and disturbing others suggests potential danger or severe impairment.
A psychiatric-mental health patient has an advance care directive on his medical record. A clinician provides treatment that disregards the patient?s directive. The clinician would be liable for which of the following?
- A. Assault
- B. Battery
- C. Medical battery
- D. False imprisonment
Correct Answer: C
Rationale: Disregarding an advance care directive and providing unauthorized treatment constitutes medical battery, a specific type of battery involving non-consensual medical intervention.
A nursing instructor is preparing a class discussion on the topic of self-determinism. Which of the following would the instructor expect to include?
- A. Personal autonomy as a key value
- B. Choices based on pleasing others
- C. Activities reflect personal goals
- D. Right to refuse treatment
- E. Lack of empowerment
Correct Answer: A,C,D
Rationale: Self-determinism involves personal autonomy, activities reflecting personal goals, and the right to refuse treatment, emphasizing patient control over their healthcare decisions.