Nokea
A nurse is working with one licensed practical nurse (PN), a student nurse and an unlicensed assistive personnel (UAP). Which newly admitted clients would be most appropriate to assign to the UAP?
- A. A 76-year-old client with severe depression
- B. A middle-aged client with an obsessive compulsive disorder
- C. An adolescent with dehydration and anorexia
- D. A young adult who is a heroin addict in withdrawal with hallucinations
Correct Answer: B
Rationale: The UAP can be assigned to care for a client with a chronic condition after an initial assessment by the nurse. This client has minimal risk of instability of condition.
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A partner is concerned because the client frequently daydreams about moving to Arizona to get away from the pollution and crowding in southern California. The nurse explains that
- A. such fantasies can gratify unconscious wishes or prepare for anticipated future events
- B. detaching or dissociating in this way postpones painful feelings
- C. converting or transferring a mental conflict to a physical symptom can lead to conflict within the partnership
- D. isolating the feelings in this way reduces conflict within the client and with others
Correct Answer: A
Rationale: such fantasies can gratify unconscious wishes or prepare for anticipated future events. Fantasy is imagined events (daydreaming) to express unconscious conflicts or gratify unconscious wishes.
The hospitalized client states, "I can't wait for anyone to take me to the bathroom, or I will wet my pants." What should the nurse do? Select all that apply.
- A. Assess the client's risk for a fall using a rating scale.
- B. Document that the client is frequently incontinent.
- C. Ensure an immediate response to the client's call light.
- D. Educate the client regarding fall prevention strategies.
- E. Place a note on the door stating, "bathroom every two hours."
- F. Request that the HCP prescribe placement of a urinary catheter.
Correct Answer: A,C,D
Rationale: A: Assessing fall risk is essential due to urgency. C: Prompt response to call light prevents rushing. D: Education on fall prevention is proactive. B is incorrect as incontinence cannot be assumed. E violates privacy. F is unnecessary and risky.
Which of the following statements describes the purpose of client restraint?
- A. Restraints are a nursing measure used to maintain client control.
- B. Restraints are an emergency intervention taken as a last resort to protect a client from imminent danger.
- C. Restraints are a therapeutic measure designed to positively reinforce client behavior.
- D. Restraints are an emergency measure that can only be taken by a nurse under the direct supervision of a physician.
Correct Answer: B
Rationale: The use of restraints as an emergency measure is taken primarily as a last resort to protect a client from harm. Typically, the nurse acts under a physician's order, but in an emergency, the nurse may restrain a client out of necessity for one hour prior to the client being seen by a physician or an advanced practice mental health provider.
Which of the following microorganisms are considered normal body flora?
- A. staphylococcus on the skin
- B. streptococcus in the nares
- C. candida albicans in the vagina
- D. pseudomonas in the blood
Correct Answer: A
Rationale: Of the choices given, only staphylococcus is considered a normal resident of the body.
A client is admitted with a diagnosis of schizophrenia. The client refuses to take medication and states "I don't think I need those medications. They make me too sleepy and drowsy. I insist that you explain their use and side effects." The nurse should understand that
- A. a referral is needed to the psychiatrist who is to provide the client with answers
- B. the client has a right to know about the prescribed medications
- C. such education is an independent decision of the individual nurse whether or not to teach clients about their medications
- D. clients with schizophrenia are at a higher risk of psychosocial complications when they know about their medication side effects
Correct Answer: B
Rationale: The client has a right to know about the prescribed medications. Clients have a right to informed consent which includes information about medications, treatments, and diagnostic studies.