Nokea
A staff member informs the nurse that his six-year-old child has head lice.
It is MOST important for the nurse to take which of the following actions?
- A. Inspect the staff member's head for louse and nits.
- B. Inform the staff member that he cannot care for clients until further notice.
- C. Request that the staff member to contact his physician.
- D. Instruct the staff member about how to use Kwell.
Correct Answer: A
Rationale: Strategy: Answers are a mix of assessments and implementations. Does this situation require assessment? Yes. Is there an appropriate assessment? Yes. (1) correct-observe for movement (louse) or small whitish oval specks that adhere to the hair shaft (nits); treat with gamma-benzene hexachloride (Kwell) (2) confirm the presence of lice before excluding from duty; if lice present, exclude from patient care until appropriate treatment has been received and shown to be effective (3) should assess first (4) should assess first, apply shampoo to dry hair and work into lather for 4-5 minutes
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The nurse is caring for a client who is terminally ill. Upon admission, the client signed advance directives indicating that she does not wish to have any resuscitative measures. The client is now in and out of consciousness. Her daughter comes to the nurse and says, 'I want everything done for my mother if she stops breathing.' How should the nurse respond?
- A. Remove the 'Do Not Resuscitate' order from the chart.
- B. Discuss the client's advance directives with the daughter.
- C. Have the daughter sign a consent form since her mother is in and out of consciousness.
- D. When the client is conscious, ask her again what her wishes are.
Correct Answer: B
Rationale: Discussing advance directives respects the client's documented wishes, clarifying the DNR order with the daughter to ensure alignment.
The multidisciplinary team decides to implement behavior modification with a client.
- A. What is the primary nursing action during implementation of behavior modification?
- B. Confirm that all staff members understand and comply with the treatment plan.
- C. Establish mutually agreed upon, realistic goals.
- D. Ensure that the potent recorders (rewards) are important to the client.
- E. Establish a fixed interval schedule for reinforcement.
Correct Answer: A
Rationale: Consistency in applying the behavior modification plan is critical for success. Confirming that all staff members understand and comply ensures consistent implementation, reducing manipulation by the client or staff. While setting goals, choosing rewards, and scheduling reinforcement are important, they are secondary to ensuring staff alignment.
Decentralized scheduling is used on a nursing unit. A chief advantage of this management strategy is that it:
- A. considers client and staff needs
- B. conserves time spent on planning
- C. frees the nurse manager to handle other priorities
- D. allows requests for special privileges
Correct Answer: A
Rationale: Decentralized staffing takes into consideration specific client needs and staff interests and abilities.
The nurse is caring for a manic client in the seclusion room, and it is time for lunch.
- A. What is the most appropriate action for the nurse to take for a manic client in the seclusion room at lunchtime?
- B. Take the client to the dining room with 1:1 supervision.
- C. Inform the client he may go to the dining room when he controls his behavior.
- D. Hold the meal until the client is able to come out of seclusion.
- E. Serve the meal to the client in the seclusion room.
Correct Answer: D
Rationale: For safety, a manic client in seclusion should remain in the seclusion room and have meals served there to maintain a controlled environment. Taking the client to the dining room risks escalation, delaying the meal is unnecessary, and linking meals to behavior control is inappropriate.
An adult is taking digoxin and furosemide. Which laboratory value is of greatest concern to the nurse?
- A. Serum digoxin of 1.2 ng/mL
- B. Serum K+ of 3.0 mEq/L
- C. BUN of 12 mg/dL
- D. Serum Mg of 1.6 mEq/L
Correct Answer: B
Rationale: Furosemide, a diuretic, can cause hypokalemia (low potassium), increasing the risk of digoxin toxicity. A serum K+ of 3.0 mEq/L is below normal (3.5-5.0 mEq/L), posing a significant risk. The digoxin level is therapeutic (0.5-2.0 ng/mL), and BUN and Mg are within normal ranges.