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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.
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The nurse manager reviews tasks delegated to unlicensed assistive personnel (UAP). Which of the following tasks requires follow-up by the nurse manager?
- A. providing perineal care to a client with an indwelling urinary catheter
- B. performing range of motion activities
- C. reminding the client how to care for their long-term colostomy
- D. ambulating a client who requires a gait belt
Correct Answer: C
Rationale: Reminding a client about colostomy care (C) involves teaching, which is outside the UAP’s scope and requires follow-up. Perineal care (A), range of motion (B), and ambulation with a gait belt (D) are appropriate UAP tasks.
During a bath, the unlicensed assistive personnel (UAP) reports to the nurse that the client has malodorous discharge from the gastrostomy tube. The nurse should initially
- A. obtain a specimen for culture.
- B. assess the drainage.
- C. place a sterile dressing around the gastrostomy tube.
- D. assess the client's temperature for fever.
Correct Answer: B
Rationale: Assessing the drainage (B) is the first step to determine the cause, such as infection or tube malfunction, guiding further action. Obtaining a culture (A), applying a dressing (C), or checking for fever (D) are secondary without initial assessment data.
The nurse is caring for assigned clients. Which of the following clients would be appropriate for the nurse to refer for an interdisciplinary conference? A client with Select all that apply.
- A. pulmonary tuberculosis with multiple prescriptions.
- B. ischemic stroke who has left-sided hemiplegia.
- C. hyperthyroidism and is scheduled for a thyroidectomy.
- D. stage one Alzheimer’s disease who lives with family.
- E. fractured tibia and fibula and is homeless.
- F. end-stage-renal disease who refuses dialysis.
Correct Answer: A, B, E, F
Rationale: TB with multiple drugs (A), stroke with hemiplegia (B), homeless with fractures (E), and dialysis refusal (F) require interdisciplinary coordination due to complex medical, social, or ethical needs. Thyroidectomy (C) and early Alzheimer’s (D) are less complex for conferencing.
The nurse is planning a staff education program on conflict resolution strategies. Which of the following strategies would be effective in resolving conflicts? Select all that apply.
- A. Utilize an empathetic response.
- B. Interrupt when comments are made that are not factual.
- C. Approach the conflict with passive behavior.
- D. Challenge inappropriate behaviors.
- E. Maintain good eye contact when speaking and listening.
Correct Answer: A, D, E
Rationale: Empathetic responses (A), challenging inappropriate behaviors (D), and maintaining eye contact (E) promote effective conflict resolution. Interrupting (B) escalates tension, and passive behavior (C) avoids resolution.
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.