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An RN enters a patient’s room to place an indwelling urinary catheter, as ordered by the health-care professional. The client is alert and oriented and tells the RN he wants to leave the hospital now and not receive further treatment. Which of the following actions by the RN would be considered false imprisonment?
- A. The RN tells the client he is not allowed to leave until the physician has released him.
- B. The RN asks the client why he wishes to leave.
- C. The RN asks the client to explain what he understands about his medical diagnosis.
- D. The RN asks the client to sign an against medical advice discharge form.
Correct Answer: A
Rationale: Step 1: The client is alert and oriented, indicating capacity to make decisions.
Step 2: The client expresses the desire to leave the hospital, exercising autonomy.
Step 3: False imprisonment occurs when a person is unlawfully restrained.
Step 4: Choice A is incorrect as it restricts the client's freedom without legal justification.
Step 5: Choices B, C, and D respect the client's autonomy and do not involve restraining.
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What are the key elements essential to the implementation of case management? (Select all that apply.)
- A. Collaborative practice teams
- B. Established critical pathways
- C. Quality management system
- D. All of the above
Correct Answer: D
Rationale: The correct answer is D because all the elements mentioned - collaborative practice teams, established critical pathways, and quality management system - are essential for effective case management. Collaborative practice teams ensure comprehensive care, critical pathways provide a structured approach to care delivery, and a quality management system ensures high standards of care. Each element plays a crucial role in the successful implementation of case management by promoting coordination, efficiency, and quality assurance. Therefore, selecting all of the above options is necessary to cover all key aspects of effective case management.
A client with limited mobility in their lower extremities is at risk for skin breakdown. Which of the following actions should the nurse take to prevent skin breakdown?
- A. Place the client in high-Fowler's position.
- B. Increase the client's intake of carbohydrates.
- C. Massage areas of skin that are darker than the surrounding skin tissue with unscented lotion.
- D. Have the client use a trapeze bar when changing position
Correct Answer: B
Rationale: The correct answer is B: Increase the client's intake of carbohydrates. Adequate nutrition, including carbohydrates, is essential for skin health and wound healing. Carbohydrates provide energy for the body's healing processes. Skin breakdown can be prevented by ensuring the client has a well-balanced diet.
A: Placing the client in high-Fowler's position is not directly related to preventing skin breakdown in this scenario.
C: Massaging areas of skin that are darker than the surrounding skin tissue with lotion may cause more harm than good, as it can increase the risk of skin breakdown.
D: Having the client use a trapeze bar when changing position is important for mobility but does not directly address the prevention of skin breakdown.
The nurse has administered 4 oz of orange juice to an alert patient whose blood glucose was 62 mg/dL. Fifteen minutes later, the blood glucose is 67 mg/dL. Which action should the nurse take next?
- A. Give the patient 4 to 6 oz more orange juice.
- B. Administer the PRN glucagon (Glucagon) 1 mg IM.
- C. Have the patient eat some peanut butter with crackers.
- D. Notify the healthcare provider about the hypoglycemia.
Correct Answer: A
Rationale: Rationale: The correct answer is A because the patient's blood glucose level has increased slightly, indicating the orange juice is working. Giving more orange juice is appropriate to continue raising the blood glucose level. Administering glucagon (B) is not necessary as the patient's glucose is improving. Eating peanut butter with crackers (C) may be too slow to raise the glucose level. Notifying the healthcare provider (D) is not needed at this point as the patient is responding to the initial intervention.
One way to determine staffing needs is to classify clients according to nursing care required. Another name for this is a(n) __________.
- A. self-scheduling
- B. supplementing staff system
- C. patient classification system (PCS)
- D. acuity system
Correct Answer: D
Rationale: The correct answer is D, acuity system. This system classifies clients based on the intensity of nursing care required. It helps determine staffing needs by matching the level of care needed with appropriate staffing levels. This method ensures that the right number and type of staff are available to meet patient needs efficiently. Choice A, self-scheduling, is about allowing staff to choose their own work schedules. Choice B, supplementing staff system, refers to adding additional staff when needed, not classifying clients. Choice C, patient classification system (PCS), is a general term and does not specifically focus on nursing care intensity like the acuity system does.
After a violent incident, staff needs to discuss what occurred. Several actions need to be taken following the incident:
- A. Debrief the staff and complete incident reports and verify that all staff are safe
- B. Reassure the violent patient that hurting staff when ill is not cause for concern
- C. Avoid any interactions
- D. Standing close to the patient while talking
Correct Answer: A
Rationale: The correct answer is A because it ensures the safety and well-being of staff by debriefing them, completing incident reports, and verifying their safety. This action promotes communication, support, and documentation after a violent incident. Reassuring the patient (B) is important but not the immediate priority. Avoiding interactions (C) is counterproductive as addressing the incident is necessary. Standing close to the patient (D) can potentially escalate the situation and compromise safety.