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In which of the following situations would the use of physical restraints most likely be justified?
- A. Mr. Y is agitated and aggressive while experiencing severe alcohol withdrawal and is not responding to chemical sedation.
- B. Mrs. U, diagnosed with dementia, was found wandering outside the hospital, and nurses have been unable to redirect her to stay on the unit.
- C. Mr. I is delirious during the acute stage of his urinary tract infection and is ringing the call bell nearly continuously.
- D. Mrs. T is frequently entering other patients' rooms and attempting to crawl into others' beds.
Correct Answer: A
Rationale: Answer A is the correct choice because it describes a situation where the client poses a risk due to agitation and aggression during severe alcohol withdrawal, and chemical sedation has not been effective. In such cases, physical restraints may be justified as a last resort to ensure the safety of the client and others. Choices B, C, and D present scenarios where alternative strategies like redirection, addressing delirium, or implementing behavioral interventions should be attempted before considering physical restraints.
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A nurse at a rehabilitation center is preparing a care plan for a 71-year-old post-stroke patient who has shown significant improvement in function and who is ready to return to the community. In the nurse's efforts to mobilize family caregiving, which of the following statements provides the most accurate criterion for inclusion in the category of 'family'?
- A. The patient's spouse, biological children, and closest friends
- B. Any unpaid person who has expressed sincere interest in the patient's condition and provided hands-on care since his admission to the facility
- C. Anyone who self-identifies as being a member of the patient's family
- D. Any individual who fulfills the patient's family functions
Correct Answer: D
Rationale: The most accurate criterion for inclusion in the category of 'family' when mobilizing family caregiving is identifying individuals who fulfill family functions. Choice D is the correct answer as it emphasizes the importance of individuals who perform essential family functions for the patient. This criterion is crucial as it prioritizes the practical support and care provided by individuals over biological relationships (Choice A), self-identification (Choice C), or willingness to provide care (Choice B), which may not always translate to fulfilling necessary family functions.
During a busy shift, a registered nurse directed an unlicensed care provider to change the dressing and perform wound care on an older adult client's surgical incision, an act that exists outside of the unlicensed care provider's scope of practice. Which of the following statements best captures the legal context of this event?
- A. The unlicensed care provider is solely responsible for the inappropriate practice.
- B. The nurse can be held liable for the actions of the unlicensed care provider.
- C. Liability rests with the nurse manager of the unit.
- D. In the absence of documented harm to the client, the action is legally permissible.
Correct Answer: B
Rationale: The correct answer is B. Under the doctrine of respondent superior, nurses can be held liable for the actions of individuals under their supervision. In this scenario, the registered nurse directed the unlicensed care provider to perform a task outside their scope of practice, making the nurse accountable for the consequences. Choice A is incorrect because the responsibility is shared between the nurse and the unlicensed care provider. Choice C is incorrect as the nurse manager may not be directly responsible for the actions of the registered nurse. Choice D is incorrect because legality is not determined solely by the absence of harm; acting within one's legal scope of practice is essential to ensure patient safety.
A newly hired nurse is being orientated in a community health center that provides care to the adjacent large Native American reservation/Canadian aboriginal reserve. Which statement by the nurse indicates a sound understanding of the Native American/First Nations population?
- A. I suppose that we will see a disproportionately high number of clients with lung and oral cancers.
- B. The high prevalence of diabetes and hypertension mean that strokes are likely to be relatively frequent in the area.
- C. It is unfortunate that many of the older Native Americans/First Nations people are unlikely to have family members involved in their care.
- D. The unique skin pigmentation of Native Americans/First Nations people means that I will have to modify my assessment techniques.
Correct Answer: B
Rationale: Diabetes, hypertension, and stroke are all higher than average in Native American/First Nations adults. Lung and oral cancers are not noted to have a higher prevalence and family is likely to be involved in the care of these older adults. The skin tone of Native American/First Nations people is not noted to require specific assessment techniques. The Native American population may have close family bonds.
How does a durable power of attorney differ from a power of attorney?
- A. It is granted by the court on behalf of an incompetent individual.
- B. It stays in effect if the individual granting it becomes incompetent.
- C. It goes into effect only after an individual becomes incompetent.
- D. It includes responsibility for managing an individual's financial assets.
Correct Answer: B
Rationale: A durable power of attorney allows competent individuals to appoint someone else to make decisions on their behalf in the event they become incompetent. Choice A is incorrect because a durable power of attorney is typically granted by the individual themselves, not the court. Choice C is incorrect as a durable power of attorney can be effective both before and after incompetency. Choice D is incorrect because managing financial assets is just one aspect of the authority granted by a power of attorney, not specifically for a durable power of attorney.
A nurse is working in an assisted living facility that has a culturally diverse older adult population. Which statement by the nurse best demonstrates cultural sensitivity?
- A. We need to ensure that both the minority population and the majority population have their health needs met.
- B. It's important to remember that minority groups do not usually express their pain explicitly.
- C. We need to build our knowledge of clients who belong to cultural and ethnic groups that we're not familiar with.
- D. We need to teach all clients that their health problems are not necessarily the result of punishment.
Correct Answer: C
Rationale: The best demonstration of cultural sensitivity by the nurse is reflected in choice C. Building a knowledge base around cultural and ethnic groups is a crucial component of providing culturally sensitive care. Choice A creates an inaccurate dichotomy between 'minority' and 'majority' populations, which is not a culturally sensitive approach. Choice B incorrectly generalizes that minority groups do not usually express their pain explicitly, which is not true for all cultural groups. Choice D suggests imposing a different belief system on clients, which is not culturally sensitive and can undermine trust and rapport with older adult clients.