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The nursing staff has finished restraining a client. In addition to determining whether anyone was injured, the staff is mandated to evaluate the incident to obtain which of the following ultimate outcomes?
- A. Coordinate documentation of the incident.
- B. Resolve negative feelings and attitudes.
- C. Improve the use of restraint procedures.
- D. Calm down before returning to the other clients.
Correct Answer: C
Rationale: Evaluating restraint incidents aims to improve procedures, ensuring safer and more effective use in the future. Documentation and calming down are secondary, and resolving feelings is not the primary goal.
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A client is taking ciprofloxacin (Cipro). Which of the following laboratory studies will not be affected by ciprofloxacin?
- A. Theophylline level.
- B. Prothrombin time (PT).
- C. Partial thromboplastin time (PTT).
- D. Total iron-binding capacity.
Correct Answer: D
Rationale: Ciprofloxacin does not typically affect total iron-binding capacity, unlike theophylline levels (drug interaction) or coagulation studies (PT/PTT).
A child has been prescribed diphenhydramine hydrochloride (Benadryl) to help control the itching from atopic dermatitis. The nurse should instruct the parents to report: Select all that apply.
- A. Weight loss.
- B. Drowsiness.
- C. Thickened bronchial secretions.
- D. Upset stomach.
- E. Bradycardia.
Correct Answer: B, C, D
Rationale: Diphenhydramine can cause drowsiness, thickened bronchial secretions, and upset stomach as side effects, which should be reported.
A 13-year-old male was kidnapped and held for ransom by two criminals. His parents asked to have him admitted to the adolescent psychiatric unit. He is sleep-deprived, filthy, alternating between sobbing and making threats to kill his captors, and then asks to go to sleep. What is the best initial plan for this client?
- A. Encourage him to talk with the Federal Bureau of Investigation (FBI) about the crime details.
- B. Develop trust and allow him to talk about his memories and feelings.
- C. Help him and his parents prepare for the future trial.
- D. Discourage him from making threats toward his captors.
Correct Answer: B
Rationale: Building trust and allowing the client to express feelings addresses immediate emotional needs and trauma, prioritizing mental health support.
The nurse is assessing a client who has a long history of uncontrolled hypertension. The nurse should assess the client for damage in which area of the eye?
- A. Iris.
- B. Cornea.
- C. Retina.
- D. Sclera.
Correct Answer: C
Rationale: Uncontrolled hypertension can cause retinopathy, damaging the retina, which should be assessed.
Which of the following signs and symptoms experienced by a child with suspected appendicitis should the nurse correctly judge to be unrelated to the transient sympathetic effects caused by the acute abdominal pain?
- A. Tachycardia.
- B. Chills.
- C. Rapid breathing.
- D. Dilated pupils.
Correct Answer: B
Rationale: Chills are not typically a sympathetic response to pain (unlike tachycardia, rapid breathing, or dilated pupils) and may indicate an infection or other complication.