Nokea
In what order should the unit manager implement interventions to address the UAP's behavior after they leave the unit without notifying the staff?
- A. Note date and time of the behavior.
- B. Discuss the issue privately with the UAP.
- C. Plan for scheduled break times.
- D. Evaluate the UAP for signs of improvement.
Correct Answer: A
Rationale: The correct order for the unit manager to implement interventions to address the UAP's behavior is to first note the date and time of the behavior. Proper documentation is crucial as it provides a factual record of the incident. This documentation can be used to address the behavior effectively and to track any patterns or improvements in the future. Discussing the issue with the UAP privately (choice B) should come after documenting the behavior. Planning for scheduled break times (choice C) is unrelated to the situation described and does not address the UAP's behavior of leaving without notifying the staff. Evaluating the UAP for signs of improvement (choice D) can only be done effectively after the behavior has been addressed and interventions have been implemented.
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A male client with schizophrenia tells the nurse that the hospital has installed cameras that watch him and listening devices that record what everyone says. Which nursing problem should the nurse document for this client?
- A. Noncompliance with medication related to thought broadcasting
- B. Situational self-esteem disturbance secondary to schizophrenia
- C. Disturbed sensory perception related to auditory hallucinations
- D. Impaired environmental interpretation related to paranoid delusions
Correct Answer: D
Rationale: The correct answer is D: Impaired environmental interpretation related to paranoid delusions. The client's belief about cameras watching and recording him is a manifestation of paranoid delusions, indicating a misinterpretation of the environment. Choice A is incorrect because thought broadcasting is not directly related to the client's belief about surveillance equipment. Choice B is incorrect as self-esteem disturbance is not the primary issue presented. Choice C is also incorrect as the client is not experiencing auditory hallucinations but rather paranoid delusions about surveillance.
After a client with leukemia undergoes a bone marrow biopsy and is found to have thrombocytopenia, which nursing assessment is most important following the procedure?
- A. Observe the aspiration site
- B. Assess body temperature
- C. Monitor skin elasticity
- D. Measure urinary output
Correct Answer: A
Rationale: The correct answer is to observe the aspiration site. Thrombocytopenia, characterized by a low platelet count, increases the risk of bleeding. Therefore, monitoring the biopsy site for bleeding or hematoma is crucial to ensure early detection and intervention. Assessing body temperature (choice B) is not directly related to the increased bleeding risk associated with thrombocytopenia. Monitoring skin elasticity (choice C) and measuring urinary output (choice D) are important assessments but are not the priority in this situation where bleeding risk needs immediate attention.
An older male was recently admitted to the rehabilitation unit with unilateral neglect syndrome as a result of a cerebrovascular accident (CVA). Which action should the nurse include in the plan of care?
- A. Provide additional light in the room to promote sensory stimulation
- B. Teach the client to turn his head from side to side for visual scanning
- C. Place a clock and calendar in the room to improve orientation
- D. Use hand and arm gestures to improve communication and comprehension
Correct Answer: B
Rationale: Teaching the client to turn his head from side to side for visual scanning is essential in addressing unilateral neglect syndrome caused by a cerebrovascular accident. This action helps improve visual awareness and assists the client in overcoming the neglect of one side of the body. Providing additional light for sensory stimulation (Choice A) may not directly address the issue of unilateral neglect. Placing a clock and calendar in the room (Choice C) may be helpful for orientation but does not specifically target unilateral neglect. Using hand and arm gestures for communication (Choice D) may aid in communication but does not directly address the visual scanning deficits associated with unilateral neglect syndrome.
After witnessing a preoperative client sign the surgical consent form, what are the legal implications of the nurse's signature on the client's form as a witness?
- A. The client voluntarily grants permission for the procedure to be done
- B. The surgeon has explained to the client why the surgery is necessary
- C. The client is competent to sign the consent without impairment of judgment
- D. The client understands the risks and benefits associated with the procedure
Correct Answer: C
Rationale: The nurse's signature on the consent form signifies that the client is competent to sign the consent without impairment of judgment. This legal implication ensures that the client possesses the necessary capacity to make decisions about their healthcare. Choice A is incorrect because the nurse's signature does not imply the client's voluntary permission for the procedure. Choice B is incorrect as it pertains to the surgeon's responsibility, not the nurse's. Choice D is incorrect as the nurse's signature does not confirm the client's understanding of the risks and benefits associated with the procedure.
In developing a plan of care for a client admitted to a mental health unit after attempting suicide by taking a handful of medications, which goal has the highest priority?
- A. Signs a no-self-harm contract
- B. Sleep for at least 6 hours nightly
- C. Attends group therapy every day
- D. Verbalizes a positive self-image
Correct Answer: A
Rationale: The correct answer is A: Signs a no-self-harm contract. Ensuring the client's immediate safety by having them commit to not engaging in self-harm is the highest priority after a suicide attempt. This measure aims to prevent further harm to the client. While sleep, group therapy, and self-image are important aspects of care, they are secondary to ensuring the client's safety in the immediate aftermath of a suicide attempt. Prioritizing the establishment of a no-self-harm contract creates a foundation for addressing other therapeutic goals in the client's care plan.