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The experienced nurse is instructing the new nurse on client safety. Which statement made by the new nurse should the experienced nurse correct?
- A. "It is very important for school-aged children to be taught_statistics related to sports."
- B. "The leading causes of death in young adults are due to substance abuse and suicide."
- C. "Older adults especially should be asked whether they have ever accidentally fallen at home."
- D. "Preschooler activity should be monitored because falls are a major cause of nonfatal injuries."
Correct Answer: B
Rationale: The leading cause of death in young adults is motor vehicle accidents, not substance abuse and suicide, which requires correction.
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The hospitalized client states, "I can't wait for anyone to take me to the bathroom, or I will wet my pants." What should the nurse do? Select all that apply.
- A. Assess the client's risk for a fall using a rating scale.
- B. Document that the client is frequently incontinent.
- C. Ensure an immediate response to the client's call light.
- D. Educate the client regarding fall prevention strategies.
- E. Place a note on the door stating, "bathroom every two hours."
- F. Request that the HCP prescribe placement of a urinary catheter.
Correct Answer: A,C,D
Rationale: A: Assessing fall risk is essential due to urgency. C: Prompt response to call light prevents rushing. D: Education on fall prevention is proactive. B is incorrect as incontinence cannot be assumed. E violates privacy. F is unnecessary and risky.
A thirty-seven year-old female in room 307 has a diagnosis of acquired immune deficiency syndrome (AIDS). Which of the following situations requires nurse intervention?
- A. A certified nursing assistant states, 'The patient in 307 is not wearing gloves shaving her legs.'
- B. A nursing assistant at the nursing station states, 'The patient in 307 has a respiratory rate of 16.'
- C. A nursing student in the cafeteria states, 'Dr. Jones told the patient in room 307 that she was going to die.'
- D. A certified nursing assistant states, 'Dr. Jones hasn't made rounds this morning.'
Correct Answer: C
Rationale: Patient confidentiality should be observed, especially in public places. The nurse should tell the nursing student do not discuss confidential information in public.
Which of the following statements describes the purpose of client restraint?
- A. Restraints are a nursing measure used to maintain client control.
- B. Restraints are an emergency intervention taken as a last resort to protect a client from imminent danger.
- C. Restraints are a therapeutic measure designed to positively reinforce client behavior.
- D. Restraints are an emergency measure that can only be taken by a nurse under the direct supervision of a physician.
Correct Answer: B
Rationale: The use of restraints as an emergency measure is taken primarily as a last resort to protect a client from harm. Typically, the nurse acts under a physician's order, but in an emergency, the nurse may restrain a client out of necessity for one hour prior to the client being seen by a physician or an advanced practice mental health provider.
A client is admitted with a diagnosis of schizophrenia. The client refuses to take medication and states "I don't think I need those medications. They make me too sleepy and drowsy. I insist that you explain their use and side effects." The nurse should understand that
- A. a referral is needed to the psychiatrist who is to provide the client with answers
- B. the client has a right to know about the prescribed medications
- C. such education is an independent decision of the individual nurse whether or not to teach clients about their medications
- D. clients with schizophrenia are at a higher risk of psychosocial complications when they know about their medication side effects
Correct Answer: B
Rationale: The client has a right to know about the prescribed medications. Clients have a right to informed consent which includes information about medications, treatments, and diagnostic studies.
A nurse is working with one licensed practical nurse (PN), a student nurse and an unlicensed assistive personnel (UAP). Which newly admitted clients would be most appropriate to assign to the UAP?
- A. A 76-year-old client with severe depression
- B. A middle-aged client with an obsessive compulsive disorder
- C. An adolescent with dehydration and anorexia
- D. A young adult who is a heroin addict in withdrawal with hallucinations
Correct Answer: B
Rationale: The UAP can be assigned to care for a client with a chronic condition after an initial assessment by the nurse. This client has minimal risk of instability of condition.