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The nurse is planning activities for a client diagnosed with depression who was just admitted to the hospital. Which therapeutic action should be implemented as part of the nurse's plan?
- A. Provide an activity that is quiet and solitary in nature.
- B. Plan nothing until the client asks to participate in the milieu.
- C. Offer the client a menu of activities and insist that the client participate in all of them.
- D. Provide a structured daily program of activities and encourage the client to participate.
Correct Answer: D
Rationale: A depressed person is often withdrawn. In addition, the person experiences difficulty concentrating, loss of interest or pleasure, low energy and fatigue, and feelings of worthlessness and poor self-esteem. The plan of care needs to provide stimulation in a structured environment. Options 1 and 2 are restrictive and offer little or no structure and stimulation. The nurse should not insist that a client participate in all activities.
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The clinic nurse wants to develop a teaching program for clients with a diagnosis of diabetes mellitus. Which strategy should the nurse initiate first in order to best meet the clients' needs?
- A. Assess the clients' functional abilities.
- B. Ensure that insurance will pay for participation in the program.
- C. Discuss the focus of the program with the multidisciplinary team.
- D. Include everyone who comes into the clinic in the teaching sessions.
Correct Answer: A
Rationale: Nurse-managed clinics focus on individualized disease prevention and health promotion and maintenance. Therefore, the nurse must first assess the clients and their needs to effectively plan the program. Options 2, 3, and 4 do not address the clients' needs related to the diagnosis.
When the nurse manager encourages staff to provide input in the decision-making process, which leadership style is being demonstrated?
- A. Autocratic
- B. Situational
- C. Democratic
- D. Laissez-faire
Correct Answer: C
Rationale: The democratic style of leadership best empowers staff toward excellence because this style of leadership allows nurses to provide input regarding the decision-making process and an opportunity to grow professionally. The autocratic style of leadership is task oriented and directive. The leader uses his or her power and position in an authoritarian manner to set and implement organizational goals. Decisions are made without input from the staff. The situational leadership style uses a style depending on the situation and events. The laissez-faire style allows staff to work without assistance, direction, or supervision.
Which actions are most appropriate for the nurse to take in the event of an accidental poisoning in a child? Select all that apply.
- A. Save vomitus for laboratory analysis.
- B. Place the child in a flat supine position.
- C. Induce vomiting if a household cleaner was ingested.
- D. Assess for airway patency, breathing, and circulation.
- E. Determine the type and amount of substance ingested.
- F. Remove any visible materials from the nose and mouth.
Correct Answer: A,D,E,F
Rationale: In the event of accidental poisoning, the poison control center is called before attempting any interventions. Additional interventions in an accidental poisoning include saving vomitus for laboratory analysis, which may assist with further treatment; assessing for airway patency, breathing, and circulation; determining the type and amount of substance ingested if possible to identify an antidote; removing any visible materials from the nose and mouth to terminate exposure; and positioning the victim with the head to the side to prevent aspiration of vomitus and assist in keeping the airway open. Vomiting is never induced in an unconscious person or one who is experiencing seizures because of the risk of aspiration. Additionally, vomiting is not induced if lye, household cleaners, hair care products, grease or petroleum products, or furniture polish was ingested because of the risk of internal burns.
A clinical nurse manager conducts an educational session for the staff nurses about case management. Which premise, if stated by one of the staff nurses, regarding case management, should necessitate a need for further teaching?
- A. Manages client care by managing the client care environment
- B. Maximizes hospital revenues while providing for optimal client care
- C. Represents a primary health prevention focus managed by a single case manager
- D. Is designed to promote appropriate use of hospital personnel and material resources
Correct Answer: C
Rationale: Case management represents an interdisciplinary health care delivery system to promote appropriate use of hospital personnel and material resources to maximize hospital revenues while providing for optimal client care. It manages client care by managing the client care environment and includes assessment and development of a plan of care, coordination of all services, referral, and follow-up.
The nurse working on an adult nursing unit is told to review the client census to determine which clients could be discharged if there are a large number of admissions from a newly declared disaster. The nurse determines that the clients with which medical situations would need to remain hospitalized? Select all that apply.
- A. Laparoscopic cholecystectomy
- B. Fractured hip, pinned 5 days ago
- C. Diabetes mellitus with blood glucose at 180 \mathrm{mg} / \mathrm{dL}(10.2 \mathrm{mmol} / \mathrm{L})
- D. Ongoing ventricular dysrhythmias while receiving procainamide
- E. Newly delivered postpartal client with a blood pressure of 146 / 94mmHg and 2+ proteinuria.
Correct Answer: D,E
Rationale: The client with ongoing ventricular dysrhythmias requires ongoing medical evaluation and treatment because of potentially lethal complications of the problem. The newly delivered postpartal client is showing classic signs for mild preeclampsia. This condition would need to be reversed before discharge. Each of the other problems listed may be managed at home with appropriate agency referrals for home care services and support from the family at home.