Nokea
The nurse is caring for assigned clients. The nurse should initially follow up on the client who
- A. has a basilar skull fracture and has bruises under their eyes.
- B. had a craniotomy and has a change in the Glasgow coma scale (GCS) from 13 to 11 in the last hour.
- C. has amyotrophic lateral sclerosis (ALS) and is requesting to have resuscitation efforts withheld.
- D. has Guillain-Barré syndrome (GBS) and is reporting lower extremity muscle weakness.
Correct Answer: B
Rationale: A GCS drop from 13 to 11 post-craniotomy (B) indicates neurological deterioration, possibly from hematoma, requiring immediate follow-up. Bruises with skull fracture (A), ALS DNR request (C), and GBS weakness (D) are less urgent, though GBS needs monitoring.
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The nurse is developing a staff in-service on negligence. A participant demonstrates correct understanding by identifying which elements must be met in a negligence lawsuit? Select all that apply.
- A. Duty owed
- B. Breach of duty owed
- C. Causation
- D. Harm or damages
- E. Beneficence
Correct Answer: A, B, C, D
Rationale: Negligence requires duty owed (A), breach of duty (B), causation (C), and harm or damages (D). Beneficence (E) is an ethical principle, not a legal element of negligence.
The emergency department (ED) nurse is caring for a client brought in after being found walking around a neighborhood without shoes, confused and disoriented. The nurse should initially
- A. obtain vital signs.
- B. perform a mental status exam.
- C. attempt to locate the client’s family.
- D. request an order for a psychiatry consultation.
Correct Answer: A
Rationale: Obtaining vital signs (A) is the initial priority to assess for physiological instability (e.g., hypothermia, hypoglycemia) in a confused client. Mental status exam (B), family contact (C), and psychiatry consult (D) follow after ensuring medical stability.
The nurse is providing the client with information regarding advanced directives. The nurse understands that giving this information supports the client's
- A. right to privacy.
- B. right to emergency care regardless of the ability to pay.
- C. C. self-determination.
- D. D. ability to receive appropriate treatment for their pain.
Correct Answer: C
Rationale: Advance directive discussions support self-determination (C) by empowering clients to make healthcare decisions. Privacy (A), emergency care (B), and pain treatment (D) are not directly related to advance directives.
The registered nurse (RN) is orienting a new RN to the charge nurse role. When delegating tasks, which task delegated to the licensed practical/vocational nurse (LPN/VN) would require follow-up from the charge nurse?
- A. Obtaining an occult stool sample for a client with ulcerative colitis.
- B. Assessing a newly admitted client with chest pain.
- C. Reinforcing teaching to a client newly diagnosed with diabetes mellitus.
- D. Providing pin care for a client with external fixation of the wrist.
Correct Answer: B
Rationale: Assessing a new client with chest pain (B) requires RN-level judgment due to potential life-threatening conditions, necessitating follow-up if delegated to an LPN. Stool sample collection (A), reinforcing teaching (C), and pin care (D) are within LPN scope.
The nurse in the emergency department is triaging a group of clients. It would be a priority for the nurse to follow up with the child
- A. reporting increased urinary frequency and pain during urination.
- B. diagnosed with leukemia who has petechiae on their torso.
- C. diagnosed with acute epiglottitis two days ago and is drooling.
- D. with otitis media who has a temperature of 101.1°F (38.4°C) and is crying.
Correct Answer: C
Rationale: Drooling in a child with acute epiglottitis (C) suggests airway obstruction, a life-threatening emergency requiring immediate follow-up. Urinary symptoms (A), petechiae in leukemia (B), and otitis media (D) are less urgent, though concerning.