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The nurse is planning care for a suicidal client who is hallucinating and delusional. Which intervention should the nurse incorporate into the nursing care plan to best assure client safety?
- A. Check the client's location every 15 minutes.
- B. Begin suicide precautions with 30-minute checks.
- C. Initiate one-to-one suicide precautions immediately.
- D. Ask the client to report suicidal thoughts immediately.
Correct Answer: C
Rationale: One-to-one suicide precautions are required for the client rescued from a suicide attempt. In this situation, additional significant information is that the client is delusional and hallucinating. Both of these factors increase the risk of unpredictable behavior, compromised judgment, and the risk of suicide. Options 1, 2, and 4 do not provide the constant supervision necessary for this client.
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The nurse is planning care for a client with the diagnosis of deep vein thrombosis (DVT) of the left leg. The client is experiencing severe edema and pain in the affected extremity. Which interventions should the nurse plan to implement in the care of this client? Select all that apply.
- A. Elevate the left leg.
- B. Apply moist heat to the left leg.
- C. Administer acetaminophen as prescribed.
- D. Ambulate in the hall three times per shift.
- E. Administer anticoagulation as prescribed.
Correct Answer: A,B,C,E
Rationale: Management of the client with DVT who is experiencing severe edema and pain includes bed rest; limb elevation; relief of discomfort with warm, moist heat and analgesics as needed; anticoagulant therapy; and monitoring for signs of pulmonary embolism. In current practice, activity restriction may not be prescribed if the client is receiving low-molecular-weight anticoagulation; however, some primary health care providers may still prefer bed rest for the client.
The client with a diagnosis of bladder cancer is to undergo weekly intravesical chemotherapy for the next 8 weeks. Which statement by the client should indicate to the nurse that the client understands how to manage urine as a biohazard?
- A. Void into a bedpan and then empty the urine into the toilet.
- B. Purchase extra bottles of scented disinfectant for daily bathroom cleansing.
- C. Have one bathroom strictly set aside for the client's use for the next 8 weeks.
- D. Disinfect the toilet with household bleach after voiding for 6 hours after a treatment.
Correct Answer: D
Rationale: Intravesical instillation involves instilling a chemotherapeutic agent into the bladder via a urethral catheter. This method of treatment provides a concentrated topical treatment with minimal systemic absorption. The client retains the medication for approximately 2 hours. After intravesical chemotherapy, the client treats the urine as a biohazard. This involves disinfecting the toilet after voiding with household bleach for 6 hours after a treatment. There is no value in using a bedpan for voiding. Scented disinfectants are of no particular use. The client does not need to have a separate bathroom for personal use.
During the admission process of a client being admitted for surgery, the client asks the nurse if a living will, prepared 3 years ago, remains in effect. Which response is most appropriate for the nurse to provide the client?
- A. Yes, a living will never expires.
- B. You need to speak with an attorney.
- C. I will call someone to answer your question.
- D. If it accurately reflects your situation and wishes.
Correct Answer: D
Rationale: The client should discuss the living will with the primary health care provider (HCP) on a regular basis to ensure that it contains the client's current wishes and desires based on the client's current health status. Option 1 is incorrect. Although the client can consult an attorney if the living will must be changed, the accurate nursing response is to tell the client that a living will should be reviewed. Option 3 is not at all helpful to the client and is, in fact, a communication block and places the client's question on hold.
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.
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.