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A nurse manager is reviewing the admission history of four adults who were admitted to the medical-surgical unit during the shift. Which of the following situations is the nurse required to disclose information to an outside agency about the client or the client's circumstances?
- A. A young adult client admitted for acute glomerulonephritis following a viral infection
- B. A dependent adult admitted for the treatment of a spiral fracture
- C. A young adult client admitted for asthma and has track marks that may indicate IV drug abuse
- D. An emancipated minor who has acute appendicitis and wants to leave the facility without treatment
Correct Answer: B
Rationale: The correct answer is B because a dependent adult admitted for the treatment of a spiral fracture falls under mandatory reporting requirements for suspected abuse or neglect. The nurse is obligated to disclose information to an outside agency to ensure the safety and well-being of the patient. In cases of suspected abuse or neglect, it is crucial to involve external agencies to investigate and protect the vulnerable adult.
Choices A, C, and D do not necessarily involve mandatory reporting to an outside agency. A young adult with glomerulonephritis or asthma with possible IV drug abuse may not require immediate disclosure unless there is a clear indication of harm or risk to the patient. An emancipated minor with acute appendicitis wanting to leave without treatment raises ethical concerns but may not involve mandatory reporting unless there are specific legal requirements in place.
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A nurse is assessing a group of clients for hospice services. The nurse should recommend hospice care for which of the following clients?
- A. A client who has diabetes mellitus and is having difficulty self-administering insulin because of poor eye sight
- B. A client who has terminal cancer and needs assistance with pain management
- C. A client who has dementia and needs help with activities of daily living
- D. A client who is recovering from a stroke and needs someone to provide care while his spouse is at work
Correct Answer: B
Rationale: The correct answer is B because hospice care is appropriate for clients with terminal illnesses who require palliative care, such as pain management. This client's terminal cancer indicates a need for hospice services to provide comfort and support during end-of-life care. Choices A, C, and D do not meet the criteria for hospice care as they do not involve terminal illness requiring palliative care. Choice A's issue can be managed with assistance, choice C's issue is related to dementia care, and choice D's issue is related to post-stroke care.
A nurse is delegating client care assignments for the shift. Which of the following tasks should the nurse delegate to an assistive personnel (AP)?
- A. Teach a client about low-sodium foods.
- B. Measure and record intake and output for a client.
- C. Perform wound irrigation for a client.
- D. Evaluate pain relief for a client following the administration of a pain medication.
Correct Answer: B
Rationale: The correct answer is B: Measure and record intake and output for a client. This task can be safely delegated to an assistive personnel (AP) as it is a non-invasive and routine task that does not involve critical thinking or interpretation. APs are trained to perform basic tasks like measuring and recording intake and output accurately under the supervision of a nurse. Other choices are incorrect because: A involves providing client education which requires critical thinking and assessment skills, C involves a procedure that requires specific training and skill, and D involves evaluating the effectiveness of pain relief which requires nursing judgment and assessment skills.
A nurse is caring for a group of clients. The nurse demonstrates adherence to the ethical principle of fidelity by doing which of the following?
- A. Keeping an appointment with a client
- B. Allowing a new mother to hold her stillborn infant
- C. Confirming that a client going for surgery has signed a consent form
- D. Refusing to disclose information about a client to the media
Correct Answer: A
Rationale: The correct answer is A: Keeping an appointment with a client. Fidelity in nursing ethics refers to the nurse's obligation to be faithful and keep promises made to clients. By keeping an appointment with a client, the nurse is demonstrating reliability and honoring their commitment, which is essential for building trust and maintaining the therapeutic relationship. Choices B, C, and D do not directly relate to fidelity. Allowing a mother to hold her stillborn infant (B) is an example of compassion and emotional support, confirming a client's surgery consent form (C) is related to autonomy and informed consent, and refusing to disclose client information to the media (D) is about confidentiality and privacy, not fidelity.
A nurse suspects that a coworker is diverting opioid analgesics. Which of the following is an adverse effect of opioid medications?
- A. Dilated pupils
- B. Euphoria
- C. Rhinorrhea
- D. Hallucinations
Correct Answer: B
Rationale: The correct answer is B: Euphoria. Opioid medications can cause euphoria as they act on the brain's reward system, leading to feelings of pleasure and well-being. This can contribute to their potential for misuse and diversion. Dilated pupils (A) are a common side effect of opioid use, not an adverse effect. Rhinorrhea (C) refers to a runny nose and is not typically associated with opioid use. Hallucinations (D) are rare but possible with high doses or in susceptible individuals. In summary, euphoria is a known adverse effect of opioid medications, making it the correct choice.
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.