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The nurse coming on duty notifies the unit of a delay due to a motor vehicle accident. The off-going nurse has an important appointment and must leave on time. How should the off-going nurse handle the situation?
- A. Ask another nurse to watch the current assigned clients until the incoming nurse arrives
- B. Tape-record a report and leave a cell phone number to call if there are any questions
- C. Tell the charge nurse of the impending need to leave and that client coverage is required
- D. Write out a report about the clients for the incoming nurse prior to leaving
Correct Answer: C
Rationale: Notifying the charge nurse ensures proper client coverage and maintains continuity of care without abandoning patients. Asking another nurse assumes their availability, tape-recording lacks interaction, and a written report alone does not ensure immediate supervision.
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Which is the best way to position a client's neck for palpation of the thyroid?
- A. flexed toward the side being examined
- B. hyperextended directly backward
- C. flexed away from the side being examined
- D. flexed directly forward
Correct Answer: A
Rationale: Flexing the neck toward the side being examined relaxes the sternocleidomastoid muscle, facilitating thyroid palpation. Other positions make access more difficult. Health Promotion and Maintenance
A hospitalized child suddenly has a seizure while his family is visiting. The nurse notes whole body rigidity followed by general jerking movements. The child vomits immediately after the seizure. A priority nursing diagnosis for the child is
- A. High risk for infection related to vomiting
- B. Altered family processes related to chronic illness
- C. Fluid volume deficit related to vomiting
- D. Risk for aspiration related to loss of consciousness
Correct Answer: D
Rationale: The tonic-clonic seizure appears suddenly and often leads to brief loss of consciousness. The greatest risk for the child is from airway blockage, as might follow aspiration.
The role of the incident report in risk management is:
- A. liability protection.
- B. to provide data for analysis by a risk manager to determine how future problems can be avoided.
- C. to discipline staff for errors.
- D. all of the above.
Correct Answer: B
Rationale: Incident reports collect data to analyze and prevent future issues, enhancing safety. They are not for liability protection or staff discipline. Safety and Infection Control
A client is admitted with severe injuries from an auto accident. The client's vital signs are BP 120/50, pulse rate 110, and respiratory rate of 28. The initial nursing intervention would be to
- A. begin intravenous therapy
- B. initiate continuous blood pressure monitoring
- C. administer oxygen therapy
- D. institute cardiac monitoring
Correct Answer: C
Rationale: Early findings of shock reveal hypoxia with rapid heart rate and rapid respirations, and oxygen is the most critical initial intervention. The other interventions are secondary to oxygen therapy.
The nurse in the outpatient mental health clinic is evaluating the effectiveness of the treatment regimen for a client with dependent personality disorder. Which of the following statements by the client would indicate that the treatment regimen has been effective?
- A. I took the bus here today because my parents could not drive me.
- B. I appreciate all the time you have spent trying to help me feel better.
- C. I know I am not good at my job because I made a mistake at work today.
- D. I plan to stay with my cousin while my parents go away on vacation next week.
Correct Answer: A
Rationale: Clients with dependent personality disorder have a persistent and extreme need to be taken care of that manifests as submissive and clinging behaviors and fear of separation. Additional characteristics of dependent personality disorder may include:• Difficulty in making day-to-day decisions • An excessive need for advice, reassurance, and nurturing from others • Lack of self-confidence or fear of doing things independently • Fear of confrontation or expressing disagreement with others • Feelings of helplessness and anxiety when alone or fear of being unable to take care of oneself The ability to make decisions about and carry out daily activities without assistance (eg, planning alternate transportation) indicate that the treatment plan has been effective