Nokea
A staff nurse is teaching a newly hired nurse about alternatives to the use of restraints on clients who are confused. Which of the following instructions should the staff nurse include?
- A. Remove clocks from the client's room
- B. Use full-length side rails on the client's bed
- C. Check on the client frequently while they are in the restroom
- D. Encourage physical activity throughout the day to expend energy
Correct Answer: D
Rationale: Encouraging physical activity throughout the day is an effective way to manage confusion in clients and reduce the need for restraints. Physical activity helps in expending energy, promoting circulation, and improving overall well-being. Removing clocks from the client's room (choice A) may not directly address the issue of confusion or reduce the need for restraints. Using full-length side rails on the client's bed (choice B) can actually increase the risk of entrapment and should be avoided. Checking on the client frequently while they are in the restroom (choice C) is important for monitoring safety but may not directly address the underlying issue of confusion and the need for restraints.
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A male Native American presents to the clinic with complaints of frequent abdominal cramping and nausea. He states that he has chronic constipation and had not had a bowel movement in five days, despite trying several home remedies. Which intervention is most important for the nurse to implement?
- A. Evaluate the stool samples for the presence of blood
- B. Assess for the presence of an impaction
- C. Determine which home remedies were used
- D. Obtain a list of prescribed medications
Correct Answer: B
Rationale: Assessing for impaction is crucial as it is a common cause of constipation and abdominal discomfort. In this scenario, the patient's symptoms of chronic constipation and no bowel movement for five days despite trying home remedies indicate a potential impaction that needs to be assessed. Evaluating stool samples for blood, determining the home remedies used, or obtaining a list of prescribed medications, while potentially relevant, are not as urgent as assessing for impaction in this situation.
When taking a history of a 3-year-old with neuroblastoma, what comment by the parents requires follow-up and is consistent with the diagnosis?
- A. The child has been listless and has lost weight.
- B. The urine is dark yellow and in small amounts.
- C. Clothes are becoming tighter across her abdomen.
- D. We notice muscle weakness and some unsteadiness.
Correct Answer: C
Rationale: The correct answer is C. Clothes becoming tighter across the abdomen is indicative of an abdominal mass, a common presentation in neuroblastoma. This symptom should be followed up on further as it aligns with the diagnosis. Choices A, B, and D are less specific to neuroblastoma. Weight loss and listlessness (Choice A) can be nonspecific symptoms, while dark yellow urine in small amounts (Choice B) may suggest dehydration or other conditions. Muscle weakness and unsteadiness (Choice D) could point towards various neurological or muscular issues but are not as directly related to neuroblastoma as the symptom described in Choice C.
A client enters the emergency department unconscious via ambulance from the client's workplace. What document should be given priority to guide the direction of care for this client?
- A. The statement of client rights and the client self-determination act
- B. Orders written by the healthcare provider
- C. A notarized original of advance directives brought in by the partner
- D. The clinical pathway protocol of the agency and the emergency department
Correct Answer: C
Rationale: In this scenario, when the client is unconscious and unable to make decisions, a notarized original of advance directives brought in by the partner should be given priority to guide the direction of care. Advance directives provide legal documentation of the client's wishes regarding healthcare decisions in situations where they cannot express their preferences. The statement of client rights and the client self-determination act (Choice A) outlines general principles but does not provide specific guidance on the client's care. Orders written by the healthcare provider (Choice B) are important but may not reflect the client's preferences. Clinical pathway protocols (Choice D) are useful for standard care pathways but do not address individual client wishes.
The charge nurse on the unit observes that one of the staff nurses is not using proper hand washing techniques. Which is the most appropriate initial approach to correct the behavior?
- A. Remind the nurse that proper hand washing prevents infection
- B. Discuss what the nurse knows about proper hand hygiene
- C. Provide a review of the hand washing policy
- D. Refer the nurse to the infection control nurse
Correct Answer: B
Rationale: The most appropriate initial approach to correct the behavior of improper hand washing by a staff nurse is to discuss what the nurse knows about proper hand hygiene. This approach helps in identifying any knowledge gaps the nurse may have and provides an opportunity to educate and correct the behavior. Option A is not the best choice as simply reminding the nurse about the importance of hand washing may not address the underlying issue of knowledge or technique. Option C, providing a review of the hand washing policy, may be necessary but is not the most immediate step to take. Option D, referring the nurse to the infection control nurse, is premature and may not be necessary if the issue can be resolved through education and communication first.
During a staff meeting, a nurse is discussing the purpose of regulatory agencies. Which of the following tasks should the nurse identify as the responsibility of state licensing boards?
- A. Monitoring evidence-based practice for clients with specific diagnoses.
- B. Ensuring that health care providers comply with regulations.
- C. Setting quality standards for accrediting health care facilities.
- D. Determining the safety of medications for administration to clients.
Correct Answer: B
Rationale: State licensing boards are primarily responsible for ensuring that health care providers comply with regulations. This includes overseeing licensure requirements, investigating complaints, and enforcing disciplinary actions. Monitoring evidence-based practice for clients with specific diagnoses is typically within the domain of professional organizations or healthcare institutions. Setting quality standards for accrediting health care facilities is usually the role of accrediting bodies such as The Joint Commission. Lastly, determining the safety of medications for administration to clients falls under the purview of regulatory agencies like the Food and Drug Administration (FDA).