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The nurse is caring for assigned clients in the behavioral health unit. The nurse should initially assess the client who
- A. has postpartum depression who appears unkempt and dejected.
- B. recently lost their family in an accident and currently states, 'I want to be with them.'
- C. has anorexia nervosa and demands that she get reweighed.
- D. refused their second dose of prescribed lithium because of a fine hand tremor.
Correct Answer: B
Rationale: The statement 'I want to be with them' (B) indicates suicidal ideation, requiring immediate assessment for safety. Postpartum depression (A), anorexia demands (C), and lithium refusal (D) are concerning but less urgent.
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The nurse serves as a witness to a client giving informed consent to the primary healthcare provider (PHCP). The nurse understands that by a client giving consent this respects the client's
- A. beneficence.
- B. autonomy.
- C. nonmaleficence.
- D. confidentiality.
Correct Answer: B
Rationale: Informed consent respects client autonomy (B), allowing self-determination in medical decisions, per ethical principles. Beneficence (A) promotes well-being, nonmaleficence (C) avoids harm, and confidentiality (D) protects information, but autonomy is central to consent.
The nurse manager is completing an annual performance evaluation of a staff nurse. Which elements should the nurse manager include when completing the evaluation? Select all that apply.
- A. The nurses’ bar-code medication administration scan rate
- B. The number of times the nurse has been absent or tardy
- C. The nurse achieving a national certification
- D. The nurses’ performance compared to other staff nurses
- E. The number of medication errors the nurse has self-reported.
Correct Answer: A, B, C, E
Rationale: Bar-code scan rate (A), absences/tardiness (B), national certification (C), and self-reported errors (E) are objective metrics for evaluation. Comparing to other nurses (D) is subjective and biased, inappropriate for inclusion.
The nurse is caring for assigned clients. The nurse should initially
- A. administer prescribed antibiotics to a client with bacterial meningitis.
- B. reposition a client with chronic back pain who reports pain rated 6/10 on the Numerical Rating Scale.
- C. remove a nitroglycerin prosthetic transdermal patch for a client with chronic angina.
- D. assess a client who had a coronary artery bypass grafting (CABG) three days ago and has a serum glucose of 135 mg/dL (7.5 mmol/L) [70-110 mg/dL, 3.9-6.1 mmol/L].
Correct Answer: A
Rationale: Antibiotics for bacterial meningitis (A) are critical to prevent rapid deterioration. Repositioning for pain (B), removing nitroglycerin patch (C), and assessing glucose of 135 (D) are less urgent.
The nurse is discussing management styles with a colleague. Which of the following nursing leadership and management-related statements is accurate?
- A. Nurse managers possess personal accountability for not only their specific acts but also acts of delegation and supervision.
- B. Nurses and nurse managers are accountable for supervising others, except for unlicensed assistive personnel (UAP).
- C. When delegated to the appropriate person, the delegating nurse is no longer responsible for ensuring the task is performed correctly.
- D. Managing care entails micromanagement of the unit's staff.
Correct Answer: A
Rationale: Nurse managers are accountable for their actions and delegated tasks, including supervision (A), per nursing standards. UAPs are included in supervision (B), delegators remain responsible (C), and micromanagement (D) is ineffective, not a management goal.
The nurse is planning client assignments for a licensed practical/vocational nurse (LPN/VN). Which client assignment would be appropriate? A client
- A. in an arm cast who is suspected to have compartment syndrome.
- B. immediately post-operative from a prostate resection reporting bladder spasms.
- C. with a paralytic ileus requiring the insertion of a nasogastric tube.
- D. newly diagnosed with Hepatitis A and requires discharge teaching.
Correct Answer: B, D
Rationale: LPNs can manage stable clients with bladder spasms post-prostate resection (B) and provide discharge teaching for Hepatitis A (D), within their scope. Compartment syndrome (A) requires RN assessment for urgent intervention, and NG tube insertion (C) is typically an RN task due to complexity.