Nokea
The nurse observes a staff member not following the plan of care for a client with an antisocial personality disorder. The nurse should:
- A. confront the staff member immediately and say, 'You know that is not the treatment plan.'
- B. write an incident report to create a paper trail of the staff member's failure to follow the planned program.
- C. ask the staff member to talk in private, and reinforce how antisocial clients try to divide staff.
- D. bring up the incident during the weekly conference so that this staff member is not assigned to work with antisocial persons again.
Correct Answer: C
Rationale: It is essential that the treatment program be followed exactly for clients with antisocial personality disorder because they are very manipulative and attempt to divide staff. However, confronting the staff member in front of the client enhances the division of staff.
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Which of the following infants is in need of additional growth assessment?
- A. Baby girl A: age 4 months, BW 7 lbs. 6 oz., present weight 14 lbs. 14 oz.
- B. Baby girl B: age 2 weeks, BW 6 lbs. 10 oz., present weight 6 lbs. 11 oz.
- C. Baby girl C: age 6 months, BW 8 lbs. 9 oz., present weight 15 lbs. 0 oz.
- D. Baby girl D: age 2 months, BW 7 lbs. 2 oz., present weight 9 lbs. 10 oz.
Correct Answer: B
Rationale: Baby B has gained only 1 oz. in 2 weeks, indicating poor growth (normal is 0.5-1 oz./day). Others show appropriate weight gain.
The nurse in the newborn nursery receives report from the previous shift. Which of the following infants should the nurse see FIRST?
- A. A two-day-old infant, lying quietly alert, heart rate of 185 bpm.
- B. A one-day-old infant, crying, and the anterior fontanel is bulging.
- C. A 12-hour-old infant, held by the mother, respirations 45 and irregular.
- D. A five-hour-old infant, sleeping, hands and feet are blue bilaterally.
Correct Answer: A
Rationale: A heart rate of 185 bpm indicates tachycardia (normal 120–160 bpm), suggesting distress or dehydration, requiring immediate assessment. Options B, C, and D are less urgent or normal.
The nurse is caring for an adult who has had nausea and vomiting for several days and is being admitted to the nursing care unit. The client can follow directions. IV fluids were started in the emergency department. Which action is the highest priority for the nurse at this time?
- A. Offer oral fluids every hour.
- B. Turn every two hours.
- C. Monitor urine output.
- D. Put client in a supine position.
Correct Answer: C
Rationale: Monitoring urine output is critical to assess hydration status and kidney function in a client with prolonged nausea and vomiting, as dehydration is a major risk. IV fluids address dehydration, making oral fluids less urgent, and turning or positioning are secondary.
A client experiencing hallucinations.
Which of the following behaviors by a client should the nurse record to indicate that the client is experiencing hallucinations?
- A. The client sits immobilized for long periods of time.
- B. The client turns and tilts his head as if talking to someone.
- C. The client expresses the belief that the physician is out to get him.
- D. The client wrings his hands and paces constantly.
Correct Answer: B
Rationale: Strategy: Think about each answer choice. (1) describes behavior associated with depression (2) correct-hallucinations are sensory perceptions for which there is no external stimulus; this option describes client behavior that would be observed when the client is responding to voices (3) describes behavior associated with delusional thinking (4) describes behavior most associated with anxiety
A client who is receiving a tube feeding around the clock.
Which of the following nursing actions is MOST appropriate?
- A. Rinse the bag and change the formula every four hours.
- B. Rinse the bag and change the formula every shift.
- C. Change the bag and formula every shift.
- D. Rinse the bag and change the formula every two hours.
Correct Answer: A
Rationale: Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) correct-there is an increased growth of organisms after four hours (2) inappropriate due to increased organism growth (3) inappropriate due to increased organism growth (4) not a necessary action to maintain asepsis