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You are caring for a group of psychiatric mental health clients. One of these clients, who has anger management and aggressive behavior concerns, has not yet gained telephone privileges. You notice an unlicensed assistive personnel (UAP) on the unit escorting this client to the telephone. After you speak to the client about the telephone privileges, the UAP tells you, 'It is unfair for this client not to be able to use the telephone when other clients are free to do so.' What should you determine about this UAP’s comment?
- A. This comment demonstrates that the unlicensed assistive personnel (UAP) favors this client.
- B. This comment indicates that the unlicensed assistive personnel (UAP) is ensuring equal rights.
- C. This comment indicates that the unlicensed assistive personnel (UAP) is preventing discrimination.
- D. This comment indicates a learning need for the unlicensed assistive personnel (UAP) relating to the therapeutic milieu.
Correct Answer: D
Rationale: The UAP’s comment (D) reflects a lack of understanding of the therapeutic milieu, where restrictions like telephone privileges are part of a care plan to manage aggression. It does not indicate favoritism (A), equal rights (B), or anti-discrimination (C), but a need for education on unit protocols.
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The nurse is caring for a client who reports that another nurse hit them. The nurse should take which action?
- A. Inquire with the nurse if this incident occurred
- B. Assess the client for any prior episodes of abuse
- C. Determine if the client has any cognitive impairments
- D. Report the client's concern to the nursing supervisor
Correct Answer: D
Rationale: Reporting the allegation to the nursing supervisor (D) is the priority to ensure proper investigation and client safety, per facility policy. Inquiring directly (A), assessing prior abuse (B), or checking cognition (C) risks bias or delays formal action.
The nurse and unlicensed assistive personnel (UAP) are caring for assigned clients. Which of the following tasks would be appropriate for the nurse to assign to UAP? Select all that apply.
- A. Transport a client with an ankle fracture to radiology.
- B. Calculate and record a client's oral intake for the shift.
- C. Ambulate a client who is eight hours post-laparoscopic surgery.
- D. Assist a client with multiple sclerosis in performing oral care.
- E. Obtain a urine culture and sensitivity sample from an indwelling urethral catheter.
Correct Answer: A, C, D
Rationale: UAPs can transport stable clients (A), ambulate post-surgical clients (C), and assist with oral care (D). Calculating intake (B) requires clinical judgment, and obtaining a urine culture (E) involves sterile technique, both RN/LPN tasks.
Which of the following are components of the definition of critical thinking? Select all that apply.
- A. Reasoned thinking
- B. Openness to alternatives
- C. Adherence to established guidelines
- D. Ability to reflect
- E. Loyalty to traditional approaches
- F. Desire to seek the truth
Correct Answer: A, B, D, F
Rationale: Critical thinking includes reasoned thinking (A), openness to alternatives (B), reflection (D), and seeking truth (F). Adherence to guidelines (C) and loyalty to tradition (E) limit the flexibility required for critical thinking.
The nurse is caring for a client receiving a prescribed diltiazem infusion. The client has the following tracing on the electrocardiogram shown in the exhibit. The nurse should perform which priority action? See the exhibit for additional client information.
- A. pause the diltiazem infusion.
- B. notify the primary healthcare physician (PHCP).
- C. assess the client's oxygen saturation and respiratory rate (RR).
- D. prepare a prescription of intravenous (IV) atropine
Correct Answer: A
Rationale: The tracing shows sinus bradycardia. The priority action would be to pause the diltiazem infusion, as this medication is a calcium channel blocker that lowers heart rate and blood pressure. If the infusion continued, it would lower the heart rate to dangerous levels, compromising cardiac output. Once paused, the nurse should contact the primary healthcare provider.
The nurse in the emergency department (ED) is triaging clients. The nurse should immediately follow up on the client who
- A. is being treated for depression and is requesting a refill of the prescribed antidepressant.
- B. is receiving external-beam radiation for breast cancer and reports blistering at the site.
- C. fell while riding their bicycle and has bruising and abrasions to the right upper extremities.
- D. reports left testicular pain and swelling with nausea and vomiting.
Correct Answer: D
Rationale: Testicular pain/swelling with nausea (D) suggests testicular torsion, an emergency requiring immediate follow-up to prevent organ loss. Depression refill (A), radiation blisters (B), and abrasions (C) are less urgent.