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The nurse is caring for a client who is critically ill and provides the nurse with an advance directive specifying a do not resuscitate (DNR) order. The client's children arrive at the bedside and report that they oppose this type of order. The nurse should take which appropriate action?
- A. Attach the advance directive to the client's medical record.
- B. Document the wishes of the client's adult children.
- C. Ask the client's family how they would want to change the document.
- D. Void the client's advance directives at the request of their children.
Correct Answer: A
Rationale: Attaching the advance directive to the medical record (A) ensures the client’s DNR wishes are followed, respecting autonomy. Documenting family wishes (B), asking for changes (C), or voiding the directive (D) are inappropriate, as family cannot override a valid directive.
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Which of the following are components of the definition of critical thinking? Select all that apply.
- A. Reasoned thinking
- B. Openness to alternatives
- C. Adherence to established guidelines
- D. Ability to reflect
- E. Loyalty to traditional approaches
- F. Desire to seek the truth
Correct Answer: A, B, D, F
Rationale: Critical thinking includes reasoned thinking (A), openness to alternatives (B), reflection (D), and seeking truth (F). Adherence to guidelines (C) and loyalty to tradition (E) limit the flexibility required for critical thinking.
The nurse is developing a care plan for a client with Bell's palsy. Which problem should the nurse prioritize in the care plan?
- A. Risk for infection
- B. Risk for disturbed sensory perception
- C. Risk for disturbed body image
- D. Risk for ineffective tissue perfusion
Correct Answer: B
Rationale: Risk for disturbed sensory perception (B) is the priority in Bell’s palsy due to facial paralysis, which can lead to corneal abrasion or oral injury. Infection (A), body image (C), and perfusion (D) are secondary concerns.
You are caring for a group of psychiatric mental health clients. One of these clients, who has anger management and aggressive behavior concerns, has not yet gained telephone privileges. You notice an unlicensed assistive personnel (UAP) on the unit escorting this client to the telephone. After you speak to the client about the telephone privileges, the UAP tells you, 'It is unfair for this client not to be able to use the telephone when other clients are free to do so.' What should you determine about this UAP’s comment?
- A. This comment demonstrates that the unlicensed assistive personnel (UAP) favors this client.
- B. This comment indicates that the unlicensed assistive personnel (UAP) is ensuring equal rights.
- C. This comment indicates that the unlicensed assistive personnel (UAP) is preventing discrimination.
- D. This comment indicates a learning need for the unlicensed assistive personnel (UAP) relating to the therapeutic milieu.
Correct Answer: D
Rationale: The UAP’s comment (D) reflects a lack of understanding of the therapeutic milieu, where restrictions like telephone privileges are part of a care plan to manage aggression. It does not indicate favoritism (A), equal rights (B), or anti-discrimination (C), but a need for education on unit protocols.
The nurse is caring for assigned clients. The nurse should immediately follow-up on the client who
- A. is being treated for pneumonia and develops restlessness.
- B. is receiving intravenous fluids for influenza and dehydration and reports a headache.
- C. has a chest drainage system in place for a hemothorax and tidaling is present in the water seal chamber.
- D. is being treated for pleurisy and is experiencing inspiratory chest pressure.
Correct Answer: A
Rationale: Restlessness in pneumonia (A) may indicate hypoxia, requiring immediate follow-up. Headache with fluids (B), tidaling in chest tube (C), and pleurisy pain (D) are expected or less urgent.
The nurse is caring for a group of preoperative clients. Which client situation requires follow-up? A client, Select all that apply.
- A. stating that they took their prescribed carbamazepine with a sip of water.
- B. receiving dextrose 5% in water (D5W) and has a blood glucose of 266 mg/dL (14.77 mmol/L) [70-110 mg/dL, 4.0-11.0 mmol/L].
- C. reporting that they shaved their abdomen for their scheduled appendectomy.
- D. reporting difficulty with their last surgery, stating they got 'a really high fever'.
- E. reporting burning upon urination and increased urinary frequency.
Correct Answer: B, C, D, E
Rationale: High blood glucose (B) risks surgical complications, shaving abdomen (C) increases infection risk, past surgical fever (D) suggests complications, and urinary symptoms (E) indicate possible UTI, all needing follow-up. Carbamazepine with water (A) is typically acceptable pre-op.