PN Management Online Practice 2017 A.

PN Management Online Practice 2017 A: A nurse in an outpatient clinic is caring for a client who has schizophrenia. For which of the following client actions should the nurse recommend transfer to an acute care facility? The client develops command hallucinations  Command hallucinations involve hearing "voices" that direct the client to take specific actions. These actions can be directed at causing self-harm or injury to others. To provide for safety of the client and others, the nurse should recommend that the client be transferred to an acute care facility. A nurse is using a critical pathway while providing care to a client who is 3 days postoperative. Which of the following events should the nurse document as a variance? The client has a circular area of nonblanchable redness on her left heel  A variance occurs when expected outcomes of the critical pathway are not met. The nurse should document that the client has a circular area of nonblanchable redness on her left heel as a variance because this indicates the initial stage of a pressure ulcer and is not an expected outcome. A nurse is preparing to reinforce discharge teaching with a client who does not speak the same language as the nurse. Which of the following actions should the nurse plan to take?  Select an interpreter who is the same gender as the client. Ensure interpreters provided by the facility have knowledge of medical terminology. Choose an interpreter from the same ethnic background as the client. A charge nurse is asked by two staff nurses to assist in resolving a conflict about holiday scheduling. Which of the following actions should the charge nurse take? Encourage each staff nurse to give up something as part of the negotiation.  The charge nurse should encourage each staff nurse to give up something as part of the negotiation so that a compromise can be reached that is a win-win situation for each party. A nurse overhears two assistive personnel discussing the details of a clients diagnosis and treatment plan int the hospital cafeteria. Which of the following actions should the nurse take? Inform the APs that the conversation violates the client’s confidentiality NURSING 112  The nurse should intervene