Nokea
The nurse notes old and new ecchymotic areas on an older adult client's arms and buttocks upon admission. The client states to the nurse in confidence that the family members frequently hit him. Which therapeutic statement should the nurse communicate in response?
- A. I have a legal obligation to report this type of abuse.
- B. Let's get these treated, and I will maintain confidence.
- C. Let's talk about ways to prevent someone from hitting you.
- D. If this happens again, you must call the emergency department.
Correct Answer: A
Rationale: The nurse should inform the client that nurses cannot maintain confidence about alleged abusive behavior and that the nurse must report situations related to abuse. The nurse avoids bargaining with the client about treatment to maintain a confidence that the nurse is legally bound to report. Options 3 and 4 delay protective action and place the client at risk for future abuse.
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A client has become physically aggressive toward staff and other clients. What action by the nurse will best assure the safety of the milieu while preserving the client's rights?
- A. Sedating the client
- B. Applying wrist restraints
- C. Contacting the client's primary health care provider
- D. Considering all possible alternative measures
Correct Answer: D
Rationale: Before applying restraints, the nurse must exhaust alternative measures to restraints such as a bed alarm, distraction, and a sitter. If the nurse determines that a restraint is necessary, its use is discussed with the client and family, and a prescription is obtained from the primary health care provider. The nurse should explain carefully to the client and family the indications for the restraint, the type of restraint selected, and the anticipated duration for its use. Sedation can be considered as a chemical restraint. The nurse avoids applying the restraint on a client who refused it to prevent client coercion and future charges of battery.
A client asks the nurse to act as a witness for an advance directive. Which is the best intervention for the nurse to implement?
- A. Suggest the nurse manager as a witness.
- B. Agree to sign the document as a witness.
- C. Notify the provider of the client's request.
- D. Help the client find an unrelated third party.
Correct Answer: D
Rationale: An advance directive addresses the withdrawal or withholding of life-sustaining interventions that can prolong life and identifies the person who will make care decisions if the client becomes incompetent. Two people unrelated to the client witness the client's signature and then sign the document signifying that the client signed the advance directive authentically. Nurses or employees of a facility in which the client is receiving care and beneficiaries of the client should not serve as a witness because of conflict of interest concerns. There is no reason to call the provider unless the absence of the advance directive interferes with client care.
The nurse performing an admission assessment notes that a client has been prescribed metoclopramide for a prolonged period. The nurse should immediately call the primary health care provider if which signs/symptoms were then noted by the nurse?
- A. Dry mouth
- B. Anxiety or irritability
- C. Excessive drowsiness
- D. Uncontrolled rhythmic movements of the face or limbs
Correct Answer: D
Rationale: If the client experiences tardive dyskinesia (rhythmic movements of the face or limbs), the nurse should call the primary health care provider because these adverse effects may be irreversible. The medication would be discontinued, and no further doses should be given by the nurse. Anxiety, irritability, and dry mouth are mild side effects that do not harm the client.
Wrist restraints have been prescribed for a client who is continuously pulling at the gastrostomy tube. The nurse develops a care plan and should determine that which findings would be negative outcomes related to the use of restraints? Select all that apply.
- A. The client is increasingly agitated.
- B. The client's left hand is pale and cold.
- C. The client's skin under the restraint is red.
- D. The client verbalizes the reason for the restraints.
- E. The client is unable to reach the gastrostomy tube with his or her hands.
- F. The client demonstrates behavior that includes biting the attending staff.
Correct Answer: A,B,C,F
Rationale: A physical restraint is a mechanical or physical device used to immobilize a client or extremity. The restraint restricts freedom of movement. Negative outcomes in the use of restraints include signs of impaired skin integrity such as redness or skin breakdown; altered neurovascular status such as cyanosis, pallor, coldness of the skin, or complaints of tingling, numbness, or pain; increased confusion, disorientation, or agitation; or injuring staff. Client verbalization of the reason for the restraints and the client's inability to reach the gastrostomy tube with his or her hands are expected outcomes.
A client who had expressed suicidal ideations upon admission is being discharged home with family. Which statement by a family member might constitute criteria for delaying discharge?
- A. The client's wife asks, 'Does he know that I've already moved out and filed for a divorce?'
- B. The client's daughter states, 'I've decided to postpone my wedding until Dad's feeling better.'
- C. The client's son states, 'One of his friends visited last week to tell us Dad's union is out on strike.'
- D. The client's brother asks, 'Will my brother be able to continue as executor of our parent's trust?'
Correct Answer: A
Rationale: Single, divorced, and widowed clients have suicide rates that are greater than those who are married. Although the client might feel responsible for his daughter's postponement of the wedding, if presented as an action to include him, the client will feel loved and cared for. Although the situation of the strike is stressful, the client will probably receive a portion of his wages and can derive hope and a sense of belonging from being a member of the union. Although being suicidal may reduce the ability to concentrate, if the client perceives the executorship positively, taking the role away reinforces the client's low self-esteem and self-worth. This statement by the client's brother also indicates a need for the client's brother to be educated about depressive illness.