Nokea
A nurse on the pediatric unit is providing room assignments for children who are to be admitted to the unit. The nurse should plan to place a child who is postoperative from an appendectomy with which of the following clients?
- A. A child who is experiencing sickle cell crisis
- B. A child who has a head injury
- C. A child who has a new diagnosis of type 1 diabetes mellitus
- D. A child who has streptococcal pharyngitis
Correct Answer: C
Rationale: The correct answer is C. Placing the postoperative appendectomy child with a child who has a new diagnosis of type 1 diabetes mellitus is appropriate because both conditions typically require close monitoring but do not pose an immediate risk to each other. The child with appendectomy may need pain management and wound care, while the child with diabetes may need monitoring of blood glucose levels and insulin administration. Placing the postoperative child with a child experiencing sickle cell crisis (A) could be risky due to the potential for infection and stress on both children. Placing the child with a head injury (B) with a postoperative child could be dangerous as the child with a head injury may need a quiet environment and close monitoring for any neurological changes. Placing the child with streptococcal pharyngitis (D) with a postoperative child could increase the risk of infection for the postoperative child.
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A volunteer assigned to the pediatric unit reports to the charge nurse for an assignment. Which of the following assignments is unsafe for the volunteer?
- A. Transporting a school-age client who is in traction to another department
- B. Reading a book to a preschool client who has AIDS
- C. Rocking an infant who was admitted for croup
- D. Playing a computer video game with an adolescent who has sickle cell disease
Correct Answer: A
Rationale: The correct answer is A because transporting a school-age client in traction requires specialized training to ensure proper handling and safety precautions. Traction devices are delicate and any mishandling could lead to injury. Reading a book to a preschool client with AIDS (B) promotes emotional support. Rocking an infant with croup (C) provides comfort. Playing a computer video game with an adolescent with sickle cell disease (D) promotes social interaction and distracts from pain.
A nurse on a medical-surgical unit has accepted a transfer to the Intensive care unit (ICU). Prior to transfer to the ICU, the nurse completes an online critical care and emergency nursing course. The nurse is demonstrating which of the following ethical principles?
- A. Nonmaleficence
- B. Veracity
- C. Autonomy
- D. Fidelity
Correct Answer: A
Rationale: The correct answer is A: Nonmaleficence. Nonmaleficence is the ethical principle of doing no harm to patients. By completing a critical care course before transferring to the ICU, the nurse is ensuring that they have the necessary knowledge and skills to provide safe and competent care to critically ill patients, thereby upholding the principle of nonmaleficence. Veracity refers to truthfulness, autonomy to patient's right to make decisions, and fidelity to keeping promises, which are not directly related to the nurse's situation in this scenario.
A nurse is caring for a client who is postoperative and reports a pain level of 8 on a scale of 0 to 10. Which of the following actions should the nurse take first?
- A. Administer the prescribed analgesic.
- B. Notify the provider of the pain level.
- C. Reposition the client for comfort.
- D. Document the pain level in the medical record.
Correct Answer: A
Rationale: The correct answer is A: Administer the prescribed analgesic first. Managing pain is a priority to ensure the client's comfort and prevent complications. Administering the analgesic promptly is essential to relieve the client's pain and improve their overall well-being. Notifying the provider (B) can be done after addressing the immediate need for pain relief. Repositioning the client (C) may provide some comfort but should come after administering pain medication. Documenting the pain level (D) is important, but addressing the pain itself takes precedence.
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 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.