Nokea
When witnessing an adult client's signature on a consent for a procedure, the nurse verifies that the consent was obtained in an appropriate manner. The nurse should verify which of the following? Select all that apply.
- A. That there was adequate disclosure of information.
- B. That the client understood the information.
- C. That there was voluntary consent on the client's part.
- D. That the client has full awareness of the potential complications.
- E. That the client's relative, spouse or legal guardian was present.
Correct Answer: A,B,C,D
Rationale: Informed consent requires adequate disclosure, client understanding, voluntary consent, and awareness of complications. A relative's presence is not mandatory unless the client is incapacitated.
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The first thing that you should do immediately after a client accident is to:
- A. Notify the doctor.
- B. Render care.
- C. Assess the client.
- D. Notify the nurse manager.
Correct Answer: C
Rationale: The first action after a client accident is to assess the client to determine the extent of injury and immediate needs, following the nursing process.
A mother reports to the nurse that she cannot afford the antibiotic azithromycin (Zithromax), which was ordered by the physician for her toddler's ear infection. Which of the following is the most appropriate action by the nurse?
- A. Instruct the mother on the importance of the medication
- B. Ask the mother if she knows anyone who could loan her the money
- C. Confer with the physician about whether a less expensive drug could be ordered
- D. Consult with the social worker
Correct Answer: C
Rationale: Conferring with the physician to explore a less expensive alternative medication addresses the mother's financial concern while ensuring treatment. Instructing on importance doesn't solve affordability, asking about loans is inappropriate, and a social worker may help later but isn't the first step.
A therapeutic milieu is:
- A. A safe environment of care that is conducive to the prevention of medical errors.
- B. A client care area that provides personal privacy and the confidentiality of medical information.
- C. A European method of design and color to promote health and wellness.
- D. The provision of a therapeutic environment of consistency to promote health.
Correct Answer: D
Rationale: A therapeutic milieu is a structured environment designed to promote healing and recovery through consistency, safety, and therapeutic interactions.
The client with borderline personality disorder spends much time around the nurse's station, making numerous minor requests. The nurse interprets these behaviors as indicating which of the following?
- A. Fears of abandonment and attention seeking
- B. Enjoyment of bothering the staff
- C. Boredom suggesting the need for something to do
- D. Lack of desire for involvement in milieu activities
Correct Answer: A
Rationale: Frequent requests and presence at the nurse's station in borderline personality disorder often reflect fears of abandonment and attention-seeking behaviors, characteristic of the disorder.
A client is receiving a continuous I.V. infusion of heparin. The nurse should monitor the client for which of the following adverse effects?
- A. Hypotension.
- B. Bleeding.
- C. Hypoglycemia.
- D. Tachycardia.
Correct Answer: B
Rationale: Heparin is an anticoagulant, and its primary adverse effect is bleeding, which the nurse should monitor closely.