Nokea
The nurse answers the psychiatric unit's desk phone. The caller identifies himself as the husband of a patient and inquires about her condition.
Which of the following responses by the nurse is MOST appropriate?
- A. I may not deny or confirm any patient's presence in this hospital.'
- B. Patients are not allowed to use this phone. Please call the patient's phone number directly.'
- C. I cannot give information over the phone. If you come in we can discuss her condition.'
- D. I will have to ask her if she wishes for me to give out that information.'
Correct Answer: B
Rationale: Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) confidentiality prohibits a professional from discussing information about the patient (2) correct-psychiatric patient retains civil rights to communicate with outside world and have reasonable access to telephones (3) breaks confidentiality (4) patient able to speak for herself
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A nursing assistant reports to the RN that a patient with anemia is complaining of weakness. Which of the following responses by the nurse to the nursing assistant is BEST?
- A. Listen to the patient's breath sounds and report back to me.'
- B. Set up the patient's lunch tray.'
- C. Obtain a diet history from the patient.'
- D. Instruct the patient to balance rest and activity.'
Correct Answer: B
Rationale: standard, unchanging procedure; decrease cardiac workload
A 48-year-old woman is seen in the outpatient clinic for complaints of irregular menses.
- A. What is the most probable cause of irregular menses in a 48-year-old woman with a history of regular periods?
- B. Emotional trauma and stress.
- C. The onset of menopause.
- D. The presence of uterine fibroids.
- E. A possible tubal pregnancy.
Correct Answer: B
Rationale: Irregular menses in a 48-year-old woman is most likely due to menopause, as ovarian function declines between ages 45- Stress lacks supporting data, fibroids cause excessive bleeding, and tubal pregnancy typically presents with missed periods and pain.
The nursing intervention that best describes treatment to deal with the behaviors of clients with personality disorders include
- A. Pointing out inconsistencies in speech patterns to correct thought disorders
- B. Accepting client and the client's behavior unconditionally
- C. Encouraging dependency in order to develop ego controls
- D. Consistent limit-setting enforced 24 hours per day
Correct Answer: D
Rationale: Consistent limit-setting enforced 24 hours per day. This helps restructure maladaptive behaviors in personality disorders.
Which diagnosis for the client with tuberculosis would have the greatest impact on public health?
- A. Ineffective breathing pattern
- B. Deficient knowledge
- C. Fatigue
- D. Ineffective family therapeutic regimen management
Correct Answer: B
Rationale: Deficient knowledge about TB transmission risks public health by increasing spread, requiring education to ensure compliance with treatment and precautions.
A client with severe multiple trauma injuries from a motor vehicle accident.
After stabilizing a client with severe multiple trauma injuries from a motor vehicle accident, which of the following actions by the nurse is BEST?
- A. Limit visiting hours to promote optimal rest.
- B. Arrange for clergy to visit with the client and family as requested.
- C. Arrange for a psychologist to visit with the family.
- D. Arrange for the family to meet with a social worker to discuss financial aid.
Correct Answer: B
Rationale: Strategy: All answers are implementations. Determine the outcome of each answer. Is it desired? (1) inappropriate (2) correct-would provide the appropriate spiritual support necessary during a crisis (3) inappropriate for the data given in the situation (4) inappropriate for the data given in the situation