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The nurse is caring for a patient who is withdrawing from heavy alcohol use and who is consequently combative and confused, despite the administration of benzodiazepines. The patient has a fractured hip that he suffered in a traumatic accident and is trying to get out of bed. What is the most appropriate action for the nurse to take?
- A. Leave the patient and get help.
- B. Obtain a physicians order to restrain the patient.
- C. Read the facilitys policy on restraints.
- D. Order soft restraints from the storeroom.
Correct Answer: B
Rationale: It is mandatory in most settings to have a physicians order before restraining a patient. Before restraints are used, other strategies, such as asking family members to sit with the patient, or utilizing a specially trained sitter, should be tried. A patient should never be left alone while the nurse summons assistance.
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The nurse, in collaboration with the patients family, is determining priorities related to the care of the patient. The nurse explains that it is important to consider the urgency of specific problems when setting priorities. What provides the best framework for prioritizing patient problems?
- A. Availability of hospital resources
- B. Family member statements
- C. Maslows hierarchy of needs
- D. The nurses skill set
Correct Answer: C
Rationale: Maslows hierarchy of needs provides a useful framework for prioritizing problems, with the first level given to meeting physical needs of the patient. Availability of hospital resources, family member statements, and nursing skill do not provide a framework for prioritization of patient problems, though each may be considered.
A nurse provides care on an orthopedic reconstruction unit and is admitting two new patients, both status post knee replacement. What would be the best explanation why their care plans may be different from each other?
- A. Patients may have different insurers, or one may qualify for Medicare.
- B. Individual patients are seen as unique and dynamic, with individual needs.
- C. Nursing care may be coordinated by members of two different health disciplines.
- D. Patients are viewed as dissimilar according to their attitude toward surgery.
Correct Answer: B
Rationale: Regardless of the setting, each patient situation is viewed as unique and dynamic. Differences in insurance coverage and attitude may be relevant, but these should not fundamentally explain the differences in their nursing care. Nursing care should be planned by nurses, not by members of other disciplines.
A patient admitted with right leg thrombophlebitis is to be discharged from an acute-care facility. Following treatment with a heparin infusion, the nurse notes that the patients leg is pain-free, without redness or edema. Which step of the nursing process does this reflect?
- A. Diagnosis
- B. Analysis
- C. Implementation
- D. Evaluation
Correct Answer: D
Rationale: The nursing actions described constitute evaluation of the expected outcomes. The findings show that the expected outcomes have been achieved. Analysis consists of considering assessment information to derive the appropriate nursing diagnosis. Implementation is the phase of the nursing process where the nurse puts the care plan into action. This nurses actions do not constitute diagnosis.
An audit of a large, university medical center reveals that four patients in the hospital have current orders for restraints. You know that restraints are an intervention of last resort, and that it is inappropriate to apply restraints to which of the following patients?
- A. A postlaryngectomy patient who is attempting to pull out his tracheostomy tube
- B. A patient in hypovolemic shock trying to remove the dressing over his central venous catheter
- C. A patient with urosepsis who is ringing the call bell incessantly to use the bedside commode
- D. A patient with depression who has just tried to commit suicide and whose medications are not achieving adequate symptom control
Correct Answer: C
Rationale: Restraints should never be applied for staff convenience. The patient with urosepsis who is frequently ringing the call bell is requesting assistance to the bedside commode; this is appropriate behavior that will not result in patient harm. The other described situations could plausibly result in patient harm; therefore, it is more likely appropriate to apply restraints in these instances.
Your patient has been admitted for a liver biopsy because the physician believes the patient may have liver cancer. The family has told both you and the physician that if the patient is terminal, the family does not want the patient to know. The biopsy results are positive for an aggressive form of liver cancer and the patient asks you repeatedly what the results of the biopsy show. What strategy can you use to give ethical care to this patient?
- A. Obtain the results of the biopsy and provide them to the patient.
- B. Tell the patient that only the physician knows the results of the biopsy.
- C. Promptly communicate the patients request for information to the family and the physician.
- D. Tell the patient that the biopsy results are not back yet in order temporarily to appease him.
Correct Answer: C
Rationale: Strategies nurses could consider include the following: not lying to the patient, providing all information related to nursing procedures and diagnoses, and communicating the patients requests for information to the family and physician. Ethically, you cannot tell the patient the results of the biopsy and you cannot lie to the patient.