Nokea
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.
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You are caring for a group of psychiatric mental health clients. One of these clients, who has anger management and aggressive behavior concerns, has not yet gained telephone privileges. You notice an unlicensed assistive personnel (UAP) on the unit escorting this client to the telephone. After you speak to the client about the telephone privileges, the UAP tells you, 'It is unfair for this client not to be able to use the telephone when other clients are free to do so.' What should you determine about this UAP’s comment?
- A. This comment demonstrates that the unlicensed assistive personnel (UAP) favors this client.
- B. This comment indicates that the unlicensed assistive personnel (UAP) is ensuring equal rights.
- C. This comment indicates that the unlicensed assistive personnel (UAP) is preventing discrimination.
- D. This comment indicates a learning need for the unlicensed assistive personnel (UAP) relating to the therapeutic milieu.
Correct Answer: D
Rationale: The UAP’s comment (D) reflects a lack of understanding of the therapeutic milieu, where restrictions like telephone privileges are part of a care plan to manage aggression. It does not indicate favoritism (A), equal rights (B), or anti-discrimination (C), but a need for education on unit protocols.
The nurse is triaging a group of pediatric clients. The nurse should first see the client who is
- A. reporting pain 5/10 on the Numerical Rating Scale after burning their right forearm.
- B. drooling and experiencing difficulty with swallowing.
- C. experiencing a temperature of 101.1°F (38.4°C) and a headache.
- D. reporting excessive thirst and has a thready peripheral pulse.
Correct Answer: B
Rationale: Drooling and difficulty swallowing (B) suggest airway obstruction, such as epiglottitis, a life-threatening emergency. Burns (A), fever with headache (C), and thirst with thready pulse (D) are concerning but less immediately critical.
A registered nurse (RN) and a licensed practical/vocational nurse (LPN/VN) are working together in a psychiatric ward. Which of the following clients can the RN assign to the LPN/VN? A client
- A. taking amitriptyline who is currently grinding their jaw and grimacing
- B. with dementia who is currently confused and disoriented
- C. with bipolar disorder with a lithium level of 2.0 mEq/L [0.6-1.2 mEq/L]
- D. with a history of chronic alcoholism currently experiencing delirium tremens
Correct Answer: B
Rationale: A client with dementia who is confused (B) is stable and suitable for LPN care, focusing on safety and routine tasks. Jaw grinding on amitriptyline (A), toxic lithium level (C), and delirium tremens (D) require RN assessment due to potential toxicity or instability.
The nurse manager has observed a staff nurse return to work late multiple times following the lunch break. The nurse manager should take which initial action?
- A. Continue to observe the nurse's behavior
- B. Reprimand the nurse with written documentation
- C. Ask the nurse to check in before and after taking their lunch break
- D. Discuss with the nurse the consequences of being late
Correct Answer: C
Rationale: Asking the nurse to check in (C) is a proactive initial step to address tardiness while maintaining professionalism and gathering data. Continued observation (A) delays action, reprimand (B) is premature, and discussing consequences (D) escalates without initial intervention.
The nurse is caring for a client with a percutaneous endoscopic gastrostomy tube. Prior to administering the next tube feeding, the nurse aspirates 80 mL of gastric residual. The nurse should then
- A. notify the physician.
- B. hold the tube feeding and recheck residual volume in one hour.
- C. administer the prescribed feeding.
- D. reposition the patient in low-Fowler's position.
Correct Answer: B
Rationale: An 80 mL gastric residual (B) indicates potential delayed gastric emptying, requiring the nurse to hold the feeding and recheck in one hour to prevent aspiration. Notifying the physician (A) is premature, administering feeding (C) risks complications, and low-Fowler’s (D) is inappropriate for feeding.