Nokea
The nurse overhears another nurse state to a client 'If you do not behave, I will restrain you.' This statement demonstrates an example
- A. battery.
- B. libel.
- C. slander.
- D. assault.
Correct Answer: D
Rationale: Threatening restraint for behavior (D) is assault, a verbal threat of harm without physical contact, per legal definitions in healthcare. Battery (A) requires physical contact, libel (B) is written defamation, and slander (C) is spoken defamation, none of which apply.
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The nurse cares for an infant undergoing a surgical repair of a total anomalous pulmonary venous return tomorrow. The doctor has talked to the parents and obtained consent. The mother tells the nurse, 'I'm not so sure about this. What if my baby dies?' The nurse's most appropriate response is:
- A. Explain the procedure to the mother.
- B. Notify the surgical team and have them come back to speak with the mother again.
- C. Reassure the mother that everything will go as planned.
- D. Tell the mother that because she has already signed the consent, she cannot change her mind now.
Correct Answer: B
Rationale: Notifying the surgical team (B) ensures the mother’s concerns are addressed by the provider, respecting her need for clarification. Explaining the procedure (A) is the physician’s role, false reassurance (C) is inappropriate, and stating consent is irrevocable (D) is incorrect and dismissive.
The nurse manager is conducting a staff in-service and announces that the staff nurses may decide when to take meal breaks, and the assignment for new admissions may be decided upon themselves. The nurse manager is demonstrating
- A. authoritative leadership style.
- B. democratic leadership style.
- C. participative leadership style.
- D. laissez-faire leadership style.
Correct Answer: D
Rationale: Allowing staff to decide meal breaks and assignments (D) reflects a laissez-faire leadership style, characterized by minimal direction and high autonomy. Authoritative (A) is directive, democratic/participative (B, C) involve shared decision-making but with more guidance.
The nurse is caring for a client who was involuntarily admitted to the behavioral health unit. The client has received a package in the mail. What action should the nurse take?
- A. Provide the client with the package
- B. Open the package to review its content
- C. Provide the package upon discharge
- D. Determine if the sender is the client's next of kin
Correct Answer: B
Rationale: Opening the package to review its content (B) ensures safety by checking for harmful items, a standard practice in behavioral health units. Giving the package immediately (A), at discharge (C), or checking the sender (D) is inappropriate without inspection.
The nurse has received the following information about assigned clients. The nurse should first assess the client with
- A. chronic obstructive pulmonary disease (COPD) and has respiratory acidosis on the most recent arterial blood gas (ABG).
- B. atrial fibrillation taking prescribed warfarin and reports black, tarry stools.
- C. diabetes mellitus who refuses to eat following the administration of glargine insulin.
- D. acute pancreatitis and reports nausea with epigastric pain rated as a 3 on the Numerical Rating Scale.
Correct Answer: B
Rationale: Black, tarry stools in a client on warfarin (B) suggest gastrointestinal bleeding, a life-threatening complication requiring immediate assessment. Respiratory acidosis (A) is concerning but less acute if stable. Refusing to eat post-insulin (C) risks hypoglycemia but is less urgent. Pancreatitis pain (D) rated 3/10 is manageable.
The nurse manager has been made aware of the following staff nurse issues. The manager should initially follow up on the staff nurse who
- A. falsified documentation on a client discharged within the last 24 hours.
- B. needs assistance completing an incident report about a medication administration error on the previous shift.
- C. was thirty minutes late and tardy to their shift and is not wearing the correct gown uniform.
- D. is suspected of alcohol impairment and is precepting a newly hired nurse.
Correct Answer: D
Rationale: Suspected alcohol impairment while precepting (C) poses an immediate safety risk to clients and staff, requiring immediate immediate manager intervention. Falsified documentation (D), incident report assistance (A), and tardiness/uniform issues (B) are serious but less urgent than impairment.