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The client is in the psychiatric unit in a medical center. Which action by the psychiatric nurse is a violation of the client's legal and civil rights?
- A. The nurse tells the client civilian clothes can be worn on the unit.
- B. The nurse allows the client to have family visits during visiting hours.
- C. The nurse delivers unopened mail and packages to the client.
- D. The nurse listens to the client talking on the telephone to a friend.
Correct Answer: D
Rationale: Eavesdropping on a client’s phone call violates privacy rights, per civil liberties. Allowing clothes, visits, or mail respects client autonomy.
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Which action by the primary nurse would require the unit manager to intervene?
- A. The nurse uses a correction fluid to correct a charting mistake.
- B. The nurse is shredding the worksheet at the end of the shift.
- C. The nurse circles an omitted medication time on the MAR.
- D. The nurse documents narcotic wastage with another nurse.
Correct Answer: A
Rationale: Using correction fluid obscures records, violating charting standards, requiring intervention. Shredding worksheets, circling omissions, or documenting wastage is appropriate.
The nurse must be knowledgeable of ethical principles. Which is an example of the ethical principle of justice?
- A. The nurse administers a placebo, and the client asks if it will help the pain.
- B. The nurse accepts a work assignment in an area in which he or she is not experienced.
- C. The nurse refuses to tell a family member the client has a positive HIV test.
- D. The nurse provides an indigent client with safe and appropriate nursing care.
Correct Answer: D
Rationale: Justice ensures equitable care, like providing safe care to an indigent client. Placebos (deception), incompetence, or confidentiality are unrelated to justice.
The charge nurse is making assignments on an oncology floor. Which client should be assigned to the most experienced nurse?
- A. The client diagnosed with leukemia who has a hemoglobin of 6 g/dL.
- B. The client diagnosed with lung cancer with a pulse oximeter reading of 89%.
- C. The client diagnosed with colon cancer who needs the colostomy irrigated.
- D. The client diagnosed with Kaposi's sarcoma who is yelling at the staff.
Correct Answer: A
Rationale: Hemoglobin of 6 g/dL indicates severe anemia, requiring complex monitoring and transfusion, best handled by an experienced nurse. Hypoxia, colostomy care, or behavior are less acute.
The male client asks the nurse, 'Should I designate my wife as durable power of attorney for health care?' Which statement would be the nurse's best response?
- A. Yes, she should be because she is your next of kin.
- B. Most people don't allow their spouse to do this.
- C. Will your wife be able to support your wishes?
- D. Your children are probably the best ones for the job.
Correct Answer: C
Rationale: Choosing a proxy involves ensuring they’ll honor the client’s wishes, a key consideration. Kinship, rarity, or children are less relevant without this focus.
The client is three (3) hours post-heart transplantation. Which data would support a complication of this procedure?
- A. The client has nausea after taking the oral antirejection medication.
- B. The client has difficulty coming off the heart-lung bypass machine.
- C. The client has saturated three (3) ABD dressing pads in one (1) hour.
- D. The client complains of pain at a '6' on a 1-to-10 scale.
Correct Answer: C
Rationale: Excessive bleeding (saturated dressings) indicates a surgical complication, requiring urgent intervention. Nausea, bypass difficulty, or moderate pain are less immediate.