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Charting are important documents that are used in court proceedings a Nurse Chona should take note that the following entry recorded would be MOST defensible in court?
- A. Large bruises on thigh upon assessment.
- B. Patient fell out of bed when reaching out for medication.
- C. Burn on the back area observed upon auscultation.
- D. Patient drunk when seen in the Emergency Room.
Correct Answer: A
Rationale: Of the options provided, documenting objective, observable findings such as large bruises on the thigh upon assessment is the most defensible entry in court. This type of entry is based on the nurse's direct observation and assessment of the patient's physical condition, which can be corroborated by other healthcare providers or evidence. It provides clear, factual information without making assumptions or subjective judgments. In court, this type of documentation can help support the nurse's credibility and reliability as a witness.
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Doing year end performance evaluation of the staff is an example of
- A. Planning
- B. Organizing
- C. Controlling
- D. Staffing
Correct Answer: C
Rationale: Conducting a year-end performance evaluation of the staff is an example of a controlling function in management. Controlling involves monitoring and evaluating the performance of employees to ensure that they are working effectively and meeting the set goals and standards. By assessing the staff's performance at the end of the year, managers can identify areas of improvement, provide feedback, and make necessary adjustments to ensure the overall success of the organization. Hence, the process of evaluating staff performance falls under the controlling function of management.
A patient with advanced dementia is no longer able to communicate verbally and displays signs of distress. What should the palliative nurse consider when assessing and managing the patient's distress?
- A. Focus solely on physical comfort measures to alleviate distress.
- B. Assume the patient's distress is solely related to physical discomfort.
- C. Explore non-verbal cues and behaviors to identify the underlying causes of distress.
- D. Administer sedative medications to manage the patient's agitation.
Correct Answer: C
Rationale: When assessing and managing distress in a patient with advanced dementia who is no longer able to communicate verbally, the palliative nurse should consider exploring non-verbal cues and behaviors to identify the underlying causes of distress. Since the patient cannot communicate through words, it is essential to pay close attention to their non-verbal cues such as facial expressions, body language, and changes in behavior. Distress in dementia patients can be caused by a variety of factors including physical discomfort, unmet needs, environmental stressors, emotional distress, or even medication side effects. By carefully observing and interpreting non-verbal cues, the nurse can gain insight into what might be causing the patient's distress and tailor interventions accordingly. Simply focusing on physical comfort measures may not address the root cause of the distress, and administering sedative medications without understanding the underlying cause is not considered best practice in palliative care for dementia patients.
The first standard step in oxygen therapy that the nurse should do is________.
- A. assess client's condition
- B. gather all the equipment and supplies
- C. prepare the client for the oxygen treatment
- D. check the chart for ordered flow rate and oxygen delivery method
Correct Answer: A
Rationale: The first standard step in oxygen therapy that the nurse should do is to assess the client's condition. Before initiating any oxygen treatment, it is essential to assess the client's respiratory status, oxygen saturation levels, vital signs, and overall condition. This initial assessment helps the nurse to determine the appropriate course of oxygen therapy based on the client's individual needs and current health status. Assessing the client's condition first ensures that the oxygen therapy provided is safe and effective for the specific needs of the client.
Nurse Maris is correct in identifying whinch of the following is a health resource problem?
- A. Increase in number of deaths fromm Pneumonia
- B. Feud between Midwife andHead of t he Sanitation Committee
- C. Absence of midwife in the communtiy to render health services
- D. High Maternal Mortality Rate
Correct Answer: C
Rationale: The correct answer, C, reflects a health resource problem. The absence of a midwife in the community means that there is a lack of a critical health resource necessary for providing essential health services, especially for pregnant women and infants. This directly impacts the access to healthcare services and can contribute to negative health outcomes, such as high maternal mortality rates. The other options do not directly address a health resource problem but rather focus on specific issues or conflicts within the community.
The patient with diagnosis of schizophrenia who has been taking Clozapine will inform the patients family that the positive effect of this drug is
- A. monthly 1iver function studies change moderately
- B. psychotic symptoms, such as hearing loss are reduced
- C. patient develops leukopenia
- D. patient's energy level and involvement in activities goes up.
Correct Answer: B
Rationale: Clozapine is an atypical antipsychotic medication primarily used in the treatment of schizophrenia. One of the positive effects of Clozapine is the reduction of psychotic symptoms experienced by the patient, such as hallucinations (not hearing loss). Clozapine is effective in managing both positive symptoms (hallucinations, delusions, disorganized thinking) and negative symptoms (apathy, social withdrawal, lack of motivation) of schizophrenia. It is known for its efficacy in reducing hallucinations and other psychotic symptoms, helping the patient to lead a more stable and functional life.