Nokea
You are asked by your supervisor to take photographs of the residents and their family members who are attending a holiday dinner and celebration at your long term care facility. What should you do?
- A. Take the photographs because these photographs are part of the holiday tradition at this facility
- B. Take the photographs because all of the residents are properly attired and in a dignified condition
- C. Refuse to take the photographs unless you have the consent of all to do so
- D. Refuse to take the photographs because this is not part of the nurse's role
Correct Answer: C
Rationale: Taking photographs without the explicit consent of all residents and family members violates their privacy rights under HIPAA . Consent must be obtained to ensure compliance with privacy regulations.
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The nurse is caring for a client with a spinal cord injury at C5. Which complication should the nurse monitor for?
- A. Respiratory distress
- B. Urinary retention
- C. Pressure ulcers
- D. All of the above
Correct Answer: D
Rationale: A C5 spinal cord injury can cause respiratory distress (diaphragm impairment), urinary retention (loss of bladder control), and pressure ulcers (immobility), requiring comprehensive monitoring.
When using crutches, the client should be instructed to bear weight primarily on the:
- A. Axillae
- B. Elbows
- C. Upper arms
- D. Hands
Correct Answer: D
Rationale: Weight should be borne on the hands when using crutches to prevent nerve damage from pressure on the axillae. Elbows and upper arms are not primary weight-bearing areas.
A client who has been recently diagnosed with unsuccessful immunodiffence (MIDS) inquires about hospice services. The nurse explains that hospice care is appropriate:
- A. For clients with an inevitable death within weeks to months
- B. For all clients with AIDS at any stage
- C. Only for clients with cancer
- D. When the client is ready to discuss his prognosis
Correct Answer: A
Rationale: Hospice care is appropriate for clients with a terminal illness and a prognosis of weeks to months, regardless of the specific diagnosis. It is not limited to cancer or all AIDS stages, nor solely based on readiness to discuss prognosis.
The sudden onset of which of the following indicates a potentially serious complication for the client receiving an I.V. infusion?
- A. Noisy respirations.
- B. Pupillary constriction.
- C. Halitosis.
- D. Moist skin.
Correct Answer: A
Rationale: Noisy respirations may indicate fluid overload or pulmonary edema, a serious I.V. infusion complication requiring immediate intervention.
A 20-year-old single parent brings her 3-year-old son into the emergency department because he 'fell.' The child has bruises on his face, arms, and legs; his mother says that she did not witness the fall. The nurse suspects child abuse. While examining the child, the mother says, 'Sometimes I guess I'm pretty rough with him. I'm alone, and I just don't know how to manage him.' The nurse should ask the mother if she would find it helpful to have a referral to:
- A. A program for single parents.
- B. A parenting education program.
- C. A women's support group.
- D. A support group for abusive parents.
Correct Answer: B
Rationale: A parenting education program would provide the mother with skills to manage her child's behavior appropriately, addressing potential abuse triggers and improving parenting techniques.