Nokea
The nurse is caring for the following assigned clients. The nurse should initially follow-up with the client who
- A. is repeatedly washing their hands.
- B. talking over others during group therapy.
- C. yelling and shouting at others.
- D. is voluntarily admitted and requesting discharge.
Correct Answer: C
Rationale: Yelling and shouting at others (C) indicates potential agitation or safety risk, requiring immediate follow-up to de-escalate and ensure unit safety. Hand washing (A), interrupting therapy (B), and discharge requests (D) are less urgent.
You may also like to solve these questions
“ Initiate intravenous fluids to a client with anorexia nervosa
Administer venlafaxine to a client with persistent depressive disorder
Consult the social worker to begin discharge planning for a client
Obtain a blood sample to evaluate a client's lithium level”
The nurse has received the following prescriptions for newly admitted clients. The nurse should initially implement which of the following?
- A. initiate intravenous fluids to a client with anorexia nervosa.
- B. administer venlafaxine to a client with persistent depressive disorder.
- C. consult the social worker to begin discharge planning for a client.
- D. obtain a blood sample to evaluate a client's lithium level.
Correct Answer: A
Rationale: Initiating IV fluids for anorexia nervosa (A) is the priority to address life-threatening dehydration and electrolyte imbalances. Administering venlafaxine (B), consulting a social worker (C), and obtaining a lithium level (D) are less urgent, as they do not address immediate physiological threats.
The charge nurse of a medical-surgical unit is informed that the nursing unit is short-staffed. Which task should the charge nurse delay in order to meet all client needs?
- A. Medication administration
- B. Daily baths
- C. Vital sign collection
- D. Hourly safety rounds
Correct Answer: B
Rationale: Daily baths (B) can be delayed as they are non-essential for immediate client safety. Medication administration (A), vital signs (C), and safety rounds (D) are critical for client care and cannot be postponed.
The nurse is caring for a client requesting to leave against medical advice. The nurse barricades the client in their room because they feel that the client is not safe to go home. The nurse is demonstrating
- A. false imprisonment.
- B. malpractice.
- C. negligence.
- D. invasion of privacy.
Correct Answer: A
Rationale: Barricading a client (A) constitutes false imprisonment, as it unlawfully restricts their freedom. Malpractice (B) involves substandard care, negligence (C) requires harm from a breach of duty, and invasion of privacy (D) involves unauthorized disclosure.
A nurse is performing disaster triage at a field hospital following a structural collapse. Advanced life support resources are limited. Which client should be assigned a black tag?
- A. A client with a penetrating head wound, unresponsive to pain, irregular respirations, and a fixed, dilated pupil
- B. A client with a chest wall bruise, shallow respirations, and tracheal deviation to the right
- C. A client with an open femur fracture, cool extremity, delayed capillary refill, and confusion
- D. A client who is found conscious, but unable to move the legs, with a distended abdomen and bruising across the lower torso
Correct Answer: A
Rationale: A black tag (A) is assigned to clients unlikely to survive, such as one with a penetrating head wound, unresponsive, irregular respirations, and fixed pupil, indicating severe brain injury. Chest trauma (B), femur fracture (C), and spinal/abdominal injury (D) have higher survival potential.
The nurse approached a client with a blood pressure cuff, and the client extended their arm to allow the nurse to obtain a reading. The nurse understands that this exemplifies what type of consent?
- A. Informed consent
- B. Implied consent
- C. Expressive consent
- D. Written consent
Correct Answer: B
Rationale: Extending an arm for a blood pressure reading (B) is implied consent, as the client’s action indicates agreement. Informed consent (A) requires explanation, expressive consent (C) is not a standard term, and written consent (D) is for procedures.