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When in doubt about using restraints on an agitated patient, it is prudent for nurses to:
- A. Restrain the patient for their own safety
- B. Use minor restraints such as a bed side rail or a tray on a wheelchair
- C. Use alternatives such as a bed alarm with increased staff supervision
- D. Avoid using any device or procedure to limit liability
Correct Answer: C
Rationale: The correct answer is C: 'Use alternatives such as a bed alarm with increased staff supervision.' The Omnibus Budget Reconciliation Act (OBRA) established strict standards on restraint use in long-term care facilities. Restraints can be considered a form of false imprisonment and neglect, leading to potential litigation. Therefore, it is advisable to avoid restraints whenever possible. A bed alarm coupled with enhanced staff supervision provides an effective and non-restrictive approach for managing an agitated patient. Choices A, B, and D are incorrect because restraining the patient, using minor restraints, or avoiding all devices without providing an alternative can pose risks to patient safety, violate regulations, or increase liability concerns.
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An older adult client tells the nurse that blockage of qi in one of the body's meridians is causing severe headaches. The health care provider has diagnosed migraines and has prescribed a triptan drug. Which action would be most appropriate for the nurse to implement?
- A. Suggest that the prescribed medicine may stimulate the flow of qi
- B. Explain the vasoconstrictive and serotonin-moderating action of triptan
- C. Instruct the client to take as many doses as needed for relief
- D. Caution the client that the headaches will grow worse if the client fails to take the medication
Correct Answer: A
Rationale: Qi is the life force that circulates through the body in invisible pathways called meridians. In this scenario, the client believes that the blockage of qi is causing severe headaches. While explaining the scientific principles underlying the drug action could be valuable, it's crucial to consider the client's belief system. Therefore, the most appropriate response is to suggest that the prescribed medicine may stimulate the flow of qi, aligning with the client's perspective. Choice B, explaining the vasoconstrictive and serotonin-moderating action of triptan, does not address the client's concerns about qi blockage. Choice C, instructing the client to take as many doses as needed, can lead to potential medication misuse. Choice D, cautioning the client about worsening headaches without medication, may induce fear and hinder effective communication with the client.
As a daughter and mother are extremely close emotionally, they made a pact years ago never to put the mother in a nursing home. Now, the physical demands of caregiving are becoming too great. What is the best way a nurse can help the daughter?
- A. Persuade her to admit her mother to a nursing home
- B. Aid her in finding help with in-home care
- C. Praise her success in being a good daughter and keeping her promise
- D. Point out her mistaken altruism
Correct Answer: B
Rationale: In this situation, the best course of action for the nurse is to aid the daughter in finding help with in-home care. Persuading her to admit her mother to a nursing home would likely cause guilt and emotional distress due to their pact. Praise alone may not address the current physical caregiving challenges. Pointing out her 'mistaken altruism' could be seen as insensitive and unhelpful. Providing practical assistance in finding in-home care can alleviate the physical demands on the daughter while still honoring the emotional commitment they made.
To minimize liability, what action should nurses take when accepting telephone orders from physicians?
- A. Ask the physician to follow up with a faxed, written order
- B. Clearly communicate the most likely diagnosis to the physician
- C. Have another staff member talk with the physician and audiotape the conversation
- D. Accept only written orders or those communicated orally, in person
Correct Answer: A
Rationale: The best action for nurses to take when accepting telephone orders from physicians to minimize liability is to ask the physician to follow up with a faxed, written order and ensure it is signed within 24 hours. This approach helps ensure clarity, accuracy, and documentation of the physician's orders, reducing the risk of misinterpretation or errors. Choices B, C, and D are incorrect. Communicating a diagnosis is outside the nurse's scope of practice and should be done by the physician. Involving another staff member to audiotape the conversation can introduce legal and practical issues. Accepting only written or orally communicated orders in person may not always be practical or feasible in urgent situations where telephone orders are necessary.
A newly hired nurse is being orientated in a community health center that provides care to the adjacent large Native American reservation/Canadian aboriginal reserve. Which statement by the nurse indicates a sound understanding of the Native American/First Nations population?
- A. I suppose that we will see a disproportionately high number of clients with lung and oral cancers.
- B. The high prevalence of diabetes and hypertension mean that strokes are likely to be relatively frequent in the area.
- C. It is unfortunate that many of the older Native Americans/First Nations people are unlikely to have family members involved in their care.
- D. The unique skin pigmentation of Native Americans/First Nations people means that I will have to modify my assessment techniques.
Correct Answer: B
Rationale: Diabetes, hypertension, and stroke are all higher than average in Native American/First Nations adults. Lung and oral cancers are not noted to have a higher prevalence and family is likely to be involved in the care of these older adults. The skin tone of Native American/First Nations people is not noted to require specific assessment techniques. The Native American population may have close family bonds.
A nurse is reading a journal article about life expectancy and various cultural groups. The article describes statistics, stating that a baby born to a black American couple has a life expectancy lower than that of a baby born to a white American couple. The article goes on to describe the life expectancy as the babies get older. Which finding would the nurse most likely identify as reflecting the life expectancy of the baby born to the black American couple by the seventh decade?
- A. Beginning to equal that of similarly aged white elders
- B. Exceeding that of similarly aged white older adults
- C. Dropping to less than half that of similarly aged white older adults
- D. Rising above that of white older adults until age 75 and then dropping
Correct Answer: A
Rationale: Historically, black Americans have experienced a lower standard of living and less access to health care than their white counterparts, leading to a lower life expectancy. However, by the seventh decade of life, survival rates for black individuals begin to equal that of similarly aged white individuals. Choice B is incorrect as it indicates a higher life expectancy for black individuals, which is not supported by the information provided. Choice C is incorrect as it suggests a drastic decrease in life expectancy for black individuals, which is not in line with the trend described. Choice D is incorrect as it implies a temporary increase in life expectancy for black individuals until age 75, which is not supported by the information that survival rates begin to equal by the seventh decade.