Nokea
The nurse manager informs the nursing staff at morning report that the clinical nurse specialist will be conducting a research study on staff attitudes toward client care. All staff are invited to participate in the study if they wish. This affirms the ethical principle of
- A. Anonymity
- B. Beneficence
- C. Justice
- D. Autonomy
Correct Answer: D
Rationale: Autonomy. Individuals must be free to make independent decisions about participation in research without coercion from others.
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The nurse is talking by telephone with a parent of a 4 year-old child who has chickenpox. Which of the following demonstrates appropriate teaching by the nurse?
- A. Chewable aspirin is the preferred analgesic
- B. Topical cortisone ointment relieves itching
- C. Supples, vesicles, and crusts will be present at one time
- D. The illness is only contagious prior to lesion eruption
Correct Answer: C
Rationale: Supples, vesicles, and crusts will be present at one time. Chickenpox lesions appear in multiple stages simultaneously.
The nurse in the emergency department is caring for assigned clients. The nurse should recognize that which of the following clients meets the criteria for involuntary admission to the mental health unit? Select all that apply.
- A. the client with major depressive disorder who has refused food and fluids for the past 4 days
- B. the client with schizophrenia who takes prescribed antipsychotic medication
- C. the client who repeatedly mumbles, 'I must kill them before they get me.'
- D. the client who states, 'I sleep on the floor rather than in a bed.'
- E. the client with cannabis found in personal belongings
Correct Answer: A,C
Rationale: Refusal of food and fluids for 4 days indicates imminent risk of harm to self due to dehydration and malnutrition, meeting involuntary admission criteria. 3: Threats of violence suggest potential harm to others, justifying involuntary admission. 2 does not indicate immediate risk, as the client is medication-compliant. 4 reflects unusual behavior but not immediate danger. 5 does not inherently indicate a psychiatric emergency requiring involuntary admission.
The nurse is performing an assessment on a child with severe airway obstruction. Which finding would the nurse anticipate?
- A. Retractions in the intercostal tissues of the thorax
- B. Chest pain aggravated by respiratory movement
- C. Cyanosis and mottling of the skin
- D. Rapid, shallow respirations
Correct Answer: A
Rationale: Retractions in the intercostal tissues of the thorax. Severe airway obstruction causes extreme intercostal retractions due to increased respiratory effort.
An adult asks the nurse about blood types. Which information should the nurse plan to include when replying?
- A. Blood typing is not always accurate.
- B. A person cannot receive a factor that he/she does not have.
- C. The universal donor is AB negative.
- D. A person who is O positive can donate blood to anyone.
Correct Answer: B
Rationale: A person cannot receive blood with antigens (factors) they lack, as it causes an immune reaction. Blood typing is accurate, O negative is the universal donor, and O positive can only donate to Rh-positive types.
A 64-year-old client is prescribed ciprofloxacin for a urinary tract infection. The nurse reminds the client to observe for and notify the health care provider immediately about which of the following?
- A. Brown-colored urine
- B. Hearing and balance problems
- C. Pain in the Achilles tendon area
- D. Sunburn
Correct Answer: C
Rationale: Ciprofloxacin is associated with Achilles tendon rupture, a serious side effect requiring immediate reporting. Other symptoms are less specific.