Nokea
A nurse is triaging clients following a mass casualty event. Which of the following clients should the nurse assess first?
- A. A client who has a small circular partial-thickness burn of the left calf
- B. A client who has a massive head injury and is experiencing seizures
- C. A client who has a splinted open fracture of left medial malleolus
- D. A client who has severe respiratory stridor and a deviated trachea
Correct Answer: D
Rationale: The correct answer is D: A client who has severe respiratory stridor and a deviated trachea. This client should be assessed first because stridor indicates airway obstruction, which can rapidly progress to respiratory failure. A deviated trachea suggests a possible tension pneumothorax, a life-threatening condition requiring immediate intervention to prevent further deterioration. Assessing and managing the airway takes priority over other injuries.
Incorrect choices:
A: A small circular partial-thickness burn of the left calf is a lower priority as it does not pose an immediate threat to life compared to airway compromise.
B: A massive head injury with seizures is serious but managing the airway is the priority in this scenario.
C: A splinted open fracture of the left medial malleolus is important but does not pose an immediate threat to life compared to airway and breathing concerns.
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A charge nurse allows two nurses who are arguing about who gets to go to lunch first to go together. The charge nurse agrees to take care of both of the nurses' clients while they are at lunch. The charge nurse is demonstrating which of the following types of conflict management?
- A. Cooperating
- B. Compromising
- C. Avoiding
- D. Competing
Correct Answer: A
Rationale: The correct answer is A: Cooperating. The charge nurse is demonstrating cooperation by taking on the responsibility of caring for both nurses' clients while they go to lunch together. This approach shows a willingness to collaborate and find a solution that benefits all parties involved. By cooperating, the charge nurse is promoting teamwork and fostering a positive work environment.
Summary of other choices:
B: Compromising - This would involve finding a middle ground or making concessions, which is not the case in this scenario.
C: Avoiding - This would involve ignoring the conflict or avoiding confrontation, which is not what the charge nurse is doing.
D: Competing - This would involve a win-lose mindset where one party wins at the expense of the other, which is not evident in this situation.
A nurse is receiving change-of-shift report at the start of the shift. Which of the following statements by the nurse giving report indicates to the oncoming nurse that she should assume total care for the client, rather than assigning tasks to the assistive personnel (AP)?
- A. The client works in the hospital radiology department.
- B. The client discussed having prior thoughts of suicide.
- C. The client's blood pressure and pulse have been fluctuating throughout the day.
- D. The client's family members have been present most of the day.
Correct Answer: C
Rationale: The correct answer is C because fluctuating blood pressure and pulse indicate unstable vital signs requiring close monitoring and immediate intervention. The nurse giving report is indicating that the client's condition is dynamic and may require frequent assessments and interventions, which necessitates the oncoming nurse assuming total care. Choices A, B, and D do not directly imply the need for total care and could potentially be managed by assistive personnel.
A nurse manager is addressing a conflict between a nurse and a client's family member who is upset about visiting hour restrictions. Which of the following statements by the nurse manager is appropriate?
- A. I understand your frustration, and I'll review the visiting policy with you.
- B. You need to follow the hospital rules or leave the premises.
- C. The nurse was just following orders, so please speak to me instead.
- D. Visiting hours are non-negotiable to ensure client safety.
Correct Answer: A
Rationale: Correct Answer: A
Rationale: Option A demonstrates empathy towards the family member's frustration and willingness to address their concerns by reviewing the visiting policy. This approach shows respect and understanding, fostering a positive relationship and potential resolution.
Summary:
B: This response is dismissive and confrontational, not conducive to resolving conflict.
C: Passing blame to the nurse and redirecting the issue does not address the family member's concerns effectively.
D: While prioritizing client safety is important, this response lacks empathy and does not address the family member's feelings.
A nurse is caring for a client who is confused and uncooperative. The client hit the nurse when she attempted to give him his medication. The nurse asks the charge nurse if she can restrain the client. The charge nurse should tell the nurse this action is a violation of the client's rights and is an example of which of the following?
- A. Defamation of character
- B. Slander
- C. False imprisonment
- D. Invasion of privacy
Correct Answer: C
Rationale: Correct Answer: C. False imprisonment
Rationale:
1. False imprisonment is the intentional restriction of a person's freedom of movement without justification.
2. Restraining the client against their will without a valid reason is a violation of their rights.
3. The client has the right to refuse treatment, and restraining them would be considered false imprisonment.
4. Defamation of character (A) and slander (B) involve damaging one's reputation through false statements.
5. Invasion of privacy (D) pertains to intrusion into a person's private affairs, not physical restraint.
A nurse is caring for a client who has a history of dementia. The client is alert and oriented to person, place, and time, and has advance directives. The client is scheduled for a procedure that requires informed consent. Which of the following persons should sign the informed consent?
- A. The client
- B. The client's son, who has a durable power of attorney
- C. The client's partner
- D. The client's daughter, who is the primary caregiver
Correct Answer: A
Rationale: The correct answer is A: The client. Informed consent must be given by the client themselves, as they are alert, oriented, and have advance directives. This ensures that the client fully understands the procedure, risks, benefits, and alternatives before giving consent. The client's autonomy and right to make decisions about their own healthcare are paramount. The other choices are incorrect because only the client themselves can provide informed consent in this scenario. The son with durable power of attorney may make decisions when the client is unable to, but since the client is alert and oriented, they should sign the consent. The partner and daughter do not have the authority to provide informed consent on behalf of the client.