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.
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Which client can best be assigned to the newly licensed practical nurse?
- A. The client receiving chemotherapy
- B. The client post-coronary bypass
- C. The client with a TURP
- D. The client with diverticulitis
Correct Answer: D
Rationale: The best client to assign to the newly licensed nurse is the most stable client. In this case, the client with diverticulitis is the most stable among the options provided. Clients receiving chemotherapy and those post-coronary bypass require specialized care and attention, making them unsuitable for a newly licensed nurse. The client with a TURP may be at risk of bleeding, needing a nurse experienced in managing such complications. Therefore, the client with diverticulitis is the most appropriate choice for the newly licensed practical nurse.
Which of the following coping mechanisms protects an individual from anxiety?
- A. denial and fantasy
- B. rationalization and suppression
- C. regression and displacement
- D. reaction formation and projection
Correct Answer: A
Rationale: The correct answer is 'denial and fantasy.' Denial involves blocking external events from awareness to avoid anxiety, while fantasy is escaping to a more comfortable, less threatening place. These mechanisms can protect individuals from anxiety by providing temporary relief or distraction. Choices B, C, and D are incorrect. Rationalization and suppression do not directly protect individuals from anxiety. Regression and displacement involve reverting to earlier developmental stages or redirecting emotions to a substitute target, which do not directly shield individuals from anxiety. Reaction formation and projection entail behaving in the opposite way to one's impulses or attributing one's feelings to others respectively, which do not directly protect individuals from anxiety.
The nurse is working with families who have been displaced by a fire in an apartment complex. What is the priority intervention during the initial assessment?
- A. Provide a liaison to meet housing needs.
- B. Attentively listen when clients describe their feelings.
- C. Offer nurturing support for clients who are confused by the events.
- D. Provide structure for clients exhibiting moderate to severe anxiety.
Correct Answer: A
Rationale: The correct answer is to provide a liaison to meet housing needs. In the initial assessment after a disaster like a fire, ensuring basic needs such as housing, clothing, and food are met is the priority. Once the physical needs are addressed, the nurse can then focus on assisting clients in managing the psychological effects of loss. Choices B, C, and D are not the priority during the initial assessment as addressing housing needs should come first to provide a sense of stability and security for the affected families.
A client is 2 days post-operative colon resection. After a coughing episode, the client's wound eviscerates. Which nursing action is most appropriate?
- A. Reinsert the protruding organ and cover with 4x4s
- B. Cover the wound with a sterile 4x4 and ABD dressing
- C. Cover the wound with a sterile saline-soaked dressing
- D. Apply an abdominal binder and manual pressure to the wound
Correct Answer: B
Rationale: In the scenario where a client's wound eviscerates, the most appropriate nursing action is to cover the wound with a sterile saline-soaked dressing. Reinserting the protruding organ, as mentioned in choice A, is incorrect because it can lead to further complications requiring the client to return to surgery. Choice B, covering the wound with a sterile 4x4 and ABD dressing, is not ideal as it may not provide adequate protection and moisture for the exposed tissue. Choice D, applying an abdominal binder and manual pressure to the wound, is inappropriate as it does not address the specific needs of wound evisceration. Covering the wound with a sterile saline-soaked dressing helps maintain a moist environment, protects the exposed tissue, and prevents infection, promoting optimal wound healing and reducing the risk of complications.
Which of the following roommates would be best for the client newly admitted with gastric resection?
- A. A client with Crohn's disease
- B. A client with pneumonia
- C. A client with gastritis
- D. A client with phlebitis
Correct Answer: D
Rationale: The most suitable roommate for the client newly admitted with gastric resection is the client with phlebitis. Phlebitis is an inflammation of the blood vessel and is not infectious, making it a safer option for the surgical client. Crohn's disease clients (choice A) have frequent stools that might spread infections to the surgical client, posing a risk. A client with pneumonia (choice B) is coughing, which can disturb the gastric client's recovery. Additionally, a client with gastritis (choice C) who is vomiting and experiencing diarrhea would also not be an ideal roommate for a client recovering from gastric resection.