Nokea
An advance directive is written and notarized according to law in the state of Colorado. This document is legal and binding:
- A. internationally.
- B. in the state of Colorado only.
- C. in the continental United States.
- D. in the county of origination only.
Correct Answer: B
Rationale: Advance directive protocols and documents are defined by each state.
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A client is refusing to stay in the hospital because he does not agree with his healthcare treatment plan. The nurse stops the client from leaving due to concern for his health. Which of these legal charges could the nurse face?
- A. False imprisonment, as the nurse is not allowing the client to leave as he has decided to.
- B. Malpractice, as the nurse is intentionally keeping the patient from making his own decisions, thus violating that nursing duty.
- C. Invasion of privacy, as the nurse is getting involved in the patient's private decisions regarding healthcare.
- D. Negligence, as the nurse ignored the clients right to choose with regard to his healthcare.
Correct Answer: A
Rationale: Refusing to let a client leave against medical advice (AMA) is a form of false imprisonment and is a legal issue for nurses.
A newborn baby exhibits a reflex that includes: hand opening, abducted and extended extremities following a jarring motion. Which of the following correctly identifies the reflex?
- A. ATNR reflex
- B. Startle reflex
- C. Grasping reflex
- D. Moro reflex
Correct Answer: D
Rationale: The moro reflex has all of the listed characteristics.
While documenting on a paper form, the nurse realizes they have made a mistake writing the progress note. What should the nurse do?
- A. Mark through the mistake with a single line, then add initials and the date and time.
- B. Use a black marker to fully cover up the mistake.
- C. Do not make any changes to the progress note but explain later in the note that a mistake was made and note what should have been written.
- D. Use whiteout to cover over the mistake and write over it.
Correct Answer: A
Rationale: If a mistake has been made, it should be corrected with a line through the mistake along with the nurse's initials and the date and time. Whiteout or a black marker that fully covers up the previous documentation is not as legally defensible and is not necessary.
A client states, 'I eat a well-balanced diet. I do not smoke. I exercise regularly, and I have a yearly checkup with my physician. What else can I do to help prevent cancer?' The nurse should respond with which of the following statements?
- A. Sleep at least 6-8 hours a night
- B. Practice monthly self-breast examination
- C. Reduce stress
- D. All of the above
Correct Answer: D
Rationale: All listed actions contribute to cancer prevention: adequate sleep supports immune function, self-breast exams aid early detection, and stress reduction enhances overall health. These complement the client's existing healthy habits.
What is the primary nutritional deficiency of concern for a strict vegetarian?
- A. vitamin C
- B. vitamin B12
- C. vitamin E
- D. magnesium
Correct Answer: B
Rationale: Vitamin B12 is the primary nutritional deficiency of concern for a strict vegetarian.