Nokea
The nurse notes the patient care assistant looking through the personal items of the client with cancer. Which action should be taken by the registered nurse?
- A. Notify the police department for investigation
- B. Report this behavior to the charge nurse
- C. Monitor the situation and document any suspicious activities
- D. Confront the patient care assistant immediately
Correct Answer: B
Rationale: The appropriate action for the registered nurse in this scenario is to report the behavior to the charge nurse. This allows for proper investigation and intervention. Inappropriate actions include notifying the police directly without following the chain of command (Choice A), monitoring without immediate action (Choice C), and confronting the assistant without involving a superior (Choice D). By reporting to the charge nurse, the situation is escalated appropriately within the healthcare setting, ensuring the well-being and safety of the client.
You may also like to solve these questions
In the emergency room, a nurse is responsible for triaging four clients injured in a motor vehicle accident. Which of the following clients should receive priority in care?
- A. A 10-year-old with lacerations on the face
- B. A 15-year-old with sternal bruises
- C. A 34-year-old with a fractured femur
- D. A 50-year-old with a dislocated elbow
Correct Answer: B
Rationale: The 15-year-old with sternal bruises should receive priority in care as this client might be experiencing airway and oxygenation problems. Airway issues take precedence in triage. The 10-year-old with lacerations on the face, although looking bad, is not in immediate distress. The 34-year-old with a fractured femur should be immobilized but can be seen after the client with sternal bruising. The 50-year-old with a dislocated elbow can also be seen later as dislocated elbows are not life-threatening compared to potential airway compromise.
During a school screening, a nurse notices small bruises on the anterior and posterior ribs of an 8-year-old Asian child. The nurse should ask the child:
- A. if the family practices coining
- B. who performs coinings
- C. if the child has fallen
- D. how long the child has been abused
Correct Answer: A
Rationale: The correct answer is to ask if the family practices coining. In Asian cultures, coining is a traditional practice believed to draw infections from the body. It involves rubbing a heated coin on the chest and torso, which can cause bruising similar to what the nurse noticed on the child's ribs. This question is important to differentiate between cultural practices and potential child abuse. Choices B, C, and D are incorrect because assuming abuse without considering cultural practices can lead to misinterpretation and inappropriate actions. It's crucial for healthcare providers to be culturally sensitive and gather all relevant information before making conclusions.
Several clients are admitted to the emergency room following a three-car vehicle accident. Which clients can be assigned to share a room in the emergency department during the disaster?
- A. The schizophrenic client experiencing visual and auditory hallucinations and the client with ulcerative colitis
- B. The client who is 6 months pregnant with abdominal pain and the client with facial lacerations and a broken arm
- C. A child with fixed and dilated pupils and his parents, and the client with a frontal head injury
- D. The client who arrives with a large puncture wound to the abdomen and the client with chest pain
Correct Answer: B
Rationale: The correct answer is to assign the client who is 6 months pregnant with abdominal pain and the client with facial lacerations and a broken arm to share a room. The pregnant client needs close monitoring due to the abdominal pain, and the client with facial lacerations and a broken arm requires immediate attention for wound care and possible fracture management. Choice A should not be assigned together as the schizophrenic client experiencing visual and auditory hallucinations needs a separate room for privacy and safety, and the client with ulcerative colitis may require isolation due to the risk of infection. Choice C is incorrect because the child with fixed and dilated pupils is likely in a critical condition and should be in a private room with parents, while the client with a frontal head injury needs a separate room for focused care. Choice D is also incorrect as the client with a large puncture wound to the abdomen needs immediate attention in a separate room, and the client with chest pain requires evaluation and monitoring in a separate setting as well.
The LPN is teaching a first-time mother about breastfeeding her newborn. Which statement, if made by the mother, would reflect that the teaching had been successful?
- A. "My baby should be having at least 4-6 wet diapers a day until 1 month."?
- B. "It's nice that breastfed babies eat a bit less than formula-fed babies."?
- C. "My baby should be nursing 8-12 times a day during this period."?
- D. "I'm a little nervous about my milk coming in tomorrow. I've heard it's uncomfortable."?
Correct Answer: C
Rationale: The correct answer is, '"My baby should be nursing 8-12 times a day during this period."?' This statement indicates successful teaching because newborns should nurse 8-12 times during the newborn period to ensure they receive adequate nutrition and establish a good milk supply. This frequency helps in meeting the baby's demands for growth and development.
Choice A is incorrect because while it mentions the appropriate number of wet diapers a day once the mother's milk comes in, it does not reflect successful teaching about breastfeeding frequency.
Choice B is incorrect because it discusses feeding amounts in comparison to formula-fed babies, which is not a direct indicator of successful breastfeeding teaching.
Choice D is incorrect because it focuses on the mother's concerns about milk coming in, not on understanding the feeding frequency needed for the newborn.
When assessing a client in crisis, what should the nurse prioritize?
- A. Allowing the client to work through independent problem-solving.
- B. Completing an in-depth evaluation of stressors and responses to the situation.
- C. Focusing on immediate stress reduction.
- D. Recommending ongoing therapy.
Correct Answer: C
Rationale: When a client is in crisis, the nurse's priority is to focus on immediate stress reduction. Crisis intervention aims to stabilize the client in the present moment by addressing the most pressing issues. Allowing the client to work through independent problem-solving (Choice A) may not be appropriate during a crisis as they might need immediate support. Completing an in-depth evaluation of stressors (Choice B) is important but not the immediate priority during a crisis. Recommending ongoing therapy (Choice D) may be considered later, but the immediate focus should be on reducing the client's stress and stabilizing the situation.