HESI COMPREHENSIVE REVIEW (NCLEX RN) EXAM 5TH ED LATEST 2023

LATEST 2023 HESI COMPREHENSIVE REVIEW (NCLEX RN) EXAM 5TH ED QUESTIONS & ANSWERS WITH EXPLANATIONS (GUARANTEED A++) HESI Comprehensive Review for the NCLEX-RN® Examination FIFTH EDITION Editor E. Tina Cuellar, PhD, WHNP, PMHCNS, BC Director of Curriculum, Review and Testing, Elsevier/HESI, Houston, Texas Table of Contents Cover image Title page Copyright Contributing Authors Reviewers Preface 1. Introduction to Testing and the NCLEX-RN® Examination Test-Taking Tips The NCLEX-RN Licensing Examination Job Analysis Studies The NCLEX-RN Computer Adaptive Testing Gentle Reminders of General Principles 2. Leadership and Management Legal Aspects of Nursing Prescriptions and Health Care Providers Review of Legal Aspects of Nursing Answers to Review Leadership and Management Review of Leadership and Management Answers to Review Disaster Nursing Nursing Management for Ebola Zika Virus Review of Disaster Nursing Answers to Review Client Evaluation Recommendations to Health Care Providers for Management of Clients with Suspected Ebola Virus Infection 3. Advanced Clinical Concepts Respiratory Failure Respiratory Failure in Children Review of Respiratory Failure Answers to Review Shock Disseminated Intravascular Coagulation (DIC) Review of Shock and DIC Answers to Review Resuscitation Review of Resuscitation Answers to Review Fluid and Electrolyte Balance Review of Fluid and Electrolyte Balance Answers to Review Electrocardiogram (ECG) Review of Electrocardiogram (ECG) Answers to Review Perioperative Care Review of Perioperative Care Answers to Review HIV Infection Pediatric HIV Infection Review of HIV Infection Answers to Review Pain: Fifth Vital Sign Review of Pain Answers to Review Death and Grief Review of Death and Grief Answers to Review 4. Medical-Surgical Nursing Communication Health Promotion and Disease Prevention Teaching/Learning Spiritual Assessment Cultural Diversity Complementary and Alternative Interventions Respiratory System Review of Respiratory System Answers to Review Renal System Review of Renal System Answers to Review Cardiovascular System Review of Cardiovascular System Answers to Review Gastrointestinal System Review of Gastrointestinal System Answers to Review Endocrine System Review of Endocrine System Answers to Review Musculoskeletal System Review of Musculoskeletal System Answers to Review Neurosensory System Neurologic System Review of Neurologic System Answers to Review Hematology and Oncology Review of Hematology and Oncology Answers to Review Reproductive System Review of Reproductive System Answers to Review Burns Review of Burns Answers to Review 5. Pediatric Nursing Growth and Development Pain Assessment and Management in the Pediatric Client Review of Child Health Promotion Answers to Review Respiratory Disorders Review of Respiratory Disorders Answers to Review Cardiovascular Disorders Review of Cardiovascular Disorders Answers to Review Neuromuscular Disorders Review of Neuromuscular Disorders Answers to Review Renal Disorders Review of Renal Disorders Answers to Review Gastrointestinal Disorders Review of Gastrointestinal Disorders Answers to Review Hematologic Disorders Review of Hematologic Disorders Answers to Review Metabolic and Endocrine Disorders Review of Metabolic and Endocrine Disorders Answers to Review Skeletal Disorders Review of Skeletal Disorders Answers to Review 6. Maternity Nursing Anatomy and Physiology of Reproduction Antepartum Nursing Care Review of Anatomy and Physiology of Reproduction and Antepartum Nursing Care Answers to Review Fetal and Maternal Assessment Techniques Review of Fetal and Maternal Assessment Techniques Answers to Review Intrapartum Nursing Care Review of Intrapartum Nursing Care Answers to Review Normal Puerperium (Postpartum) Review of Normal Puerperium (Postpartum) Answers to Review The Normal Newborn Review of the Normal Newborn Answers to Review High-Risk Disorders Review of High-Risk Disorders Answers to Review Postpartum High-Risk Disorders Review of Postpartum High-Risk Disorders Answers to Review Newborn High-Risk Disorders Effects on the Neonate of Substance Abuse Review of Newborn High-Risk Disorders Answers to Review 7. Psychiatric Nursing Therapeutic Communication Coping Styles (Defense Mechanisms) Treatment Modalities Review of Therapeutic Communication and Treatment Modalities Answers to Review Anxiety and Related Disorders Anxiety Disorders, Obsessive-Compulsive and Related Disorders, and Traumatic and Stressor Related Disorders Review of Anxiety Disorders, Obsessive-Compulsive and Related Disorders, and Traumatic and Stressor Related Disorders Answers to Review Somatic Symptom Disorder and Related Disorders Review of Somatic Symptom Disorder and Related Disorders Answers to Review Dissociative Disorders Review of Dissociative Disorders Answers to Review Personality Disorders (DSM-5 Criteria) Review of Personality Disorders Answers to Review Eating Disorders Review of Eating Disorders Answers to Review Mood Disorders Review of Mood Disorders Answers to Review Schizophrenia Spectrum and Other Psychotic Disorders Review of Thought Disorders Substance Abuse Disorder Substance Use Disorder Review of Substance Abuse Disorder Answers to Review Abuse Review of Abuse Answers to Review Neurocognitive Disorder (DSM-5) Review of Neurocognitive Disorders Answers to Review Childhood and Adolescent Disorders Review of Childhood and Adolescent Disorders Answers to Review 8. Gerontologic Nursing Theories of Aging Physiologic Changes Neurocognitive Disorder (NCD): Dementia Psychosocial Changes Health Maintenance and Preventive Care Review of Gerontologic Nursing Answers to Review Appendixes A. Normal Values B. Recommended Daily Requirements and Food Sources C. Common Laboratory Tests Index Contributing Authors Safa’a Al-Arabi, PhD, RN, MSN, MPH, Associate Professor and Accelerated BSN Track Administrator, University of Texas Medical Branch, School of Nursing, Galveston, Texas E. Tina Cuellar, PhD, WHNP, PMHCNS, BC, Director of Curriculum, Review and Testing, Elsevier/Education/HESI, Houston, Texas Claudine Dufrene, PhD, RN-BC, GNP-BC, CNE, Assistant Professor, University of St. Thomas, Carol and Odis Peavy School of Nursing, Houston, Texas Shelby L. Garner, PhD, RN, CNE, Assistant Professor and Fulbright Scholar, Baylor University, Louise Herrington School of Nursing, Dallas, Texas Sandy Jemison, MSN, RN, Assistant Professor, Cox College of Nursing and Health Sciences, Springfield, Missouri Lucindra Campbell-Law, PhD, ANP, PMHNP, BC, Professor, Carol and Odis Peavy School of Nursing, University of St. Thomas, Houston, Texas Necole Leland, MSN, RN, PNP, CPN, Instructor, University of Nevada, Las Vegas, School of Nursing, Las Vegas, Nevada Rosemary Pine, PhD, RN, BC, CDE, Review Course Director, Review and Testing, Elsevier/Education/HESI, Houston, Texas Katherine Ralph, MSN, RN, Nurse Manager Curriculum, Review and Testing, Elsevier/Education/HESI, Houston, Texas Reviewers Judy Carlyle, MNSc, RN, ARNEC Program Director, Arkansas Rural Nursing Education Consortium (ARNEC), Nashville, Arkansas Susan Golden, MSN, RN, Dean of Health, Division of Health, Eastern New Mexico University-Roswell, Roswell, New Mexico Rose A. Harding, MSN, RN, Instructor, Coordinator of Standardization Test Evaluation Committee, JoAnne Gay Dishman, Department of Nursing, Lamar University, Beaumont, Texas Rosanna M. Henry, MSN, RN, Instructor and Director, Irene Fritzky Lab, School of Nursing, Duquesne University, Pittsburgh, Pennsylvania Donna Walker Hubbard, MSN, RN, CNNe, Retired Assistant Professor, University of Mary Hardin–Baylor, Belton, Texas Paula Celeste Hughes, MSN, RN, Nursing Faculty, Practical Nursing, Georgia Northwestern Technical College, Rome, Georgia Cheryl A. Lehman, PhD, RN, CNS-BC, RN-BC, CRRN, Retired Clinical Professor, School of Nursing, University of Texas Health Science Center at San Antonio, Nursing Consultant, Lehman Consulting LLC, San Antonio, Texas Donna Wilsker, MSN, RN, Assistant Professor, Dishman Department of Nursing, Lamar University, Beaumont, Texas Nancee Wozney, PhD, RN, Dean of Nursing and Allied Health/Human Services, Nursing Department, Minnesota State College–Southeast Technical, Winona, Minnesota Preface Welcome to HESI Comprehensive Review for the NCLEX-RN® Examination with online study exams by HESI. Congratulations! This outstanding review manual with online study exams is designed to prepare nursing students for what is very likely the most important examination they will ever take—the NCLEX-RN Licensing Examination. As a graduate of an RN nursing program, the student has the basic knowledge required to pass tests and perform safely and successfully in the clinical area. HESI Comprehensive Review for the NCLEX-RN® Examination allows the nursing student to prepare for the NCLEX-RN licensure examination in a structured way. • Organize nursing basic knowledge previously learned. • Review content learned during basic nursing curriculum. •Identify weaknesses in content knowledge so study effort can be focused appropriately. • Develop test-taking skills so application of safe nursing practice from knowledge previously learned can be demonstrated. • Reduce anxiety level by increasing predictability of ability to correctly answer NCLEX-type questions. • Boost test-taking confidence by being well prepared and knowing what to expect. Organization Chapter 1, Introduction to Testing and the NCLEX-RN® Examination, gives an overview of the NCLEX-RN licensing exam history and test plan for the examination. A review of the nursing process, updated with the latest NANDA-approved nursing diagnoses, client needs, and prioritizing nursing care, is also presented. Chapter 2, Leadership and Management, reviews the legal aspects of nursing, leadership and management, and disaster nursing. Chapter 3, Advanced Clinical Concepts, presents nursing assessment, analysis (nursing diagnoses), and planning and intervention at the highest level of practice. Topics reviewed include respiratory failure, shock, disseminated intravascular coagulation (DIC), resuscitation, fluid and electrolyte balance, IV therapy, acid–base balance, electrocardiogram (ECG), perioperative care, HIV, pain, and death and grief. Chapters 4 through 8, Medical-Surgical Nursing, Pediatric Nursing, Maternity Nursing, Psychiatric Nursing, and Gerontologic Nursing, are presented in traditional clinical areas. Each clinical area is divided into physiologic components, with essential knowledge about basic anatomy, growth and development, pharmacology and medication calculation, nutrition, communication, client and family education, acute and chronic care, leadership and management, complimentary and alternative interventions, cultural and spiritual diversity, and clinical decision making threaded throughout the different components. Open-ended–style questions with the answers appear at the end of each chapter, which encourage the student to think in depth about the content that is presented throughout the particular chapter. When a variety of learning mechanisms is used, students have the opportunity to comprehensively prepare for the NCLEX exam; these strategies include: • Reading the manual. • Discussing content with others. • Answering open-ended questions. • Practicing with study exams that simulate the licensure examination. These learning experiences are all different ways that students should use to prepare for the NCLEX exam. The purpose of the open-ended questions appearing at the end of the chapter is not a focused practice session on managing NCLEX-style multiple-choice questions, but rather a learning approach that allows for more in-depth thinking about specific topics in the chapter. Practice with multiple-choice questions alone cannot provide the depth of critical thinking and analysis possible with the short-answer questions at the end of the chapter. In addition, the open-ended questions presented at the end of the chapter provide a summary experience that helps students focus on the main topics that were covered in the chapter. Teachers use open-ended questions to stimulate the critical thinking process, and HESI Comprehensive Review for the NCLEX-RN® Examination facilitates the critical thinking process by posing the same type of questions the teacher might ask. When students need to practice multiple-choice questions, the online study exams on Evolve offer extensive opportunities for practice and skill building to improve their test-taking abilities. The online study exams include six content-specific exams (Medical-Surgical Nursing, Pharmacology, Pediatrics, Fundamentals, Maternity, and Psychiatric-Mental Health Nursing) and two comprehensive exams patterned after categories on the NCLEX-RN exam. The online study exams on Evolve can be accessed as many times as necessary, and the questions from one study exam are not contained on another study exam. For instance, the Medical-Surgical study exam does not contain questions that are on the Pediatrics study exam. The purpose of the study exams is to provide practice and exposure to the critical thinking–style questions that students will encounter on the NCLEX-RN exam. However, the study exams should not be used to predict performance on the actual NCLEX exam. Only the HESI Exit Exam, a secure, computerized exam that simulates the NCLEX test plan and has evidence-based results from numerous research studies indicating a high level of accuracy in predicting NCLEX success, is offered as a true predictor exam. Students are allowed unlimited practice on each online study exam so that they can be sure to have the opportunity to review all of the rationales for the questions. Here is a plan for a student to use with the online study exams: • Step 1: Take the RN study exam without studying for it to see where your strengths and weaknesses are. • Step 2: After going over the content that relates to the study questions on a particular clinical area (e.g., Pediatrics, Medical-Surgical, or Maternity), review that section of the manual, and take the test again to determine if you have been able to improve your scores. • Step 3: Purposely miss every question on the exam so that you can view the rationales for every question. • Step 4: Take the exam again under timed conditions at the pace that you would have to progress in order to complete the NCLEX exam in the time allowed (approximately 1 minute per question.) See if being placed under time constraints affects your performance. • Step 5: Put the exam away for a while, and continue review and remediation with other textbooks, other resources, and the results of any HESI secure exams that you have taken at your school. Then, take the study exams again to see if your performance improves after in-depth study and following a few weeks’ break from these questions. Step 5 represents a good activity in preparation for the HESI Exit Exam presented in your final semester of the nursing program, especially if you have not used the online study exams for several weeks. Repeated exposure to the questions, however, will make them less useful over time because students tend to memorize the answers. For this reason, these tests are useful only for practice and not prediction of NCLEX-RN success. The tendency to memorize the questions after viewing them multiple times falsely elevates a student’s score on the study exams. Additional assistance for students studying for the NCLEX-RN Licensing Examination can be obtained from a variety of online products in the Elsevier family. Many nursing schools have also adopted the following: • HESI Examinations—A comprehensive set of examinations designed to prepare nursing students for the NCLEX exam. They include customized electronic remediation from current Elsevier textbooks and multimedia, as well as additional practice questions. Each student is given an individualized report detailing exam results and is allowed to view questions and rationales for items that were answered incorrectly. The electronic remediation, a complementary feature of the specialty and exit exams, can be filed by the student for later study. • HESI Practice Test—This is the ideal way to practice for the NCLEX exam. With more than 1200 practice questions included in this online test bank, nursing students can access practice exams 24 hours a day, 7 days a week. HESI Practice Test questions are written at the critical thinking level so that students are tested not for memorization but for their skills in clinical application. Students select a test option (either a clinical specialty or a comprehensive exam), and HESI Practice Test automatically supplies a series of critical-thinking practice questions. NCLEX exam–style questions include multiple-choice and alternate-item formats and are accompanied by correct answers and rationales. • HESI RN Case Studies—These prepare students to manage complex patient conditions and to make sound clinical judgments. These online case studies cover a broad range of physiologic and psychosocial alterations, plus related management, pharmacology, and therapeutic concepts. • HESI Patient Reviews—These are designed to teach and assess students’ retention of core nursing content. These online interactive reviews provide a firsthand look at safe and effective nursing care. • HESI Live Review —A live review course is presented by an expert faculty member who has additional instruction in working with students who are preparing to take the NCLEX exam. Students are presented with a workbook and practice NCLEX-style questions that are used during the course. • Evolve eBooks—Online versions of all of the Mosby, Saunders, and Elsevier textbooks used in the student’s nursing curriculum are presented. Search across titles, highlight, make notes, and more—all on your computer. • Elsevier Simulations—Virtual versions simulate the clinical environment. These multilayered, complex, supplemental simulations enable students to experience clinical assignments without the need for actual clinical space. • Elsevier Courses—These are created by experts using instructional design principles. This interactive content engages students with reading, animation, video, audio, interactive exercises, and assessments. 1 Introduction to Testing and the NCLEX-RN® Examination Three cheers for you! You have made the wise decision to prepare, in a structured way, for the NCLEX-RN®. A. You have already successfully completed a basic nursing program and are well acquainted with your ability to take and pass tests and to perform successfully in the clinical area. B. You have the basic knowledge required to pass the licensing examination. However, it is wise to: 1. Organize your knowledge. 2. Review content learned during the years of your basic nursing curriculum. 3. Identify weaknesses in content knowledge so that you can focus your study time appropriately. 4. Develop test-taking skills so you can demonstrate the knowledge you have. 5. Reduce your level of anxiety by increasing your predictability. 6. Know what to expect. Remember: knowledge is power. You are powerful when you are well prepared and know what to expect. HESI Hint The most essential element of nursing care is client safety. Caring is the hallmark of nursing. Nursing practice includes the nursing process integrated with fundamental components, including but not limited to, caring, communication, culture and spirituality, teaching, and learning, as well as documentation of the integration of each of these elements. H E S I H i n t Most questions are written in a positive style. H E S I H i n t Negative-style questions will contain key words that denote the negative style. Examples 1. “Which response indicates to the nurse a need to reteach the client about…?” (Which information/understanding by the client is incorrect?) 2. “Which prescription (order) should the nurse question?” (Which prescription is unsafe, not beneficial, inappropriate to this client situation, etc…?) Test-Taking Tips There are no absolute ways to ensure that examination questions will always be answered correctly. These testtaking tips are guidelines to help the student study and understand the examination questions. On the NCLEXRN examination, many different areas are tested with each question. For example, a question may on the surface be a medical/surgical or pediatric question, but included in the question can be such topics as communication, nutrition, growth and development, medication, client and family education, and safety. A. Understanding the question 1. Determine whether the question is written in a positive or negative style. a. A positive style may ask what the nurse should do or ask for the best or first action to implement. b. A negative style may ask what the nurse should avoid, which prescription the nurse should question, or which behavior indicates the need for reteaching the client. 2. Find the key words in the question. a. Ask yourself which words or phrases provide the critical information. b. This information may be the age of the client, the setting, the timing, a set of symptoms or behaviors, or any number of other factors. c. For example, the nursing actions for a 10-year-old 1-day postop are different from those for a 70-yearold 1-hour postop. 3. Rephrase the question in your own words. a. This will help you eliminate nonessential information in the question and help you determine the correct answer. b. Ask yourself, “What is this question really asking?” c. While keeping the options covered, rephrase the question in your own words. 4. Rule out options. a. Based on your knowledge, you can probably identify one or two options that are clearly incorrect. b. Physically mark through those options on the test booklet if allowed. Mentally mark through those options in your head if using a computer. c. Now differentiate between the remaining options, considering your knowledge of the subject and related nursing principles, such as roles of the nurse, the nursing process, the ABCs (airway, breathing, and circulation), CAB (circulation, airway, and breathing for cardiopulmonary resuscitation [CPR]), and Maslow’s hierarchy of needs. B. General guidelines about test taking 1. Consider the content of the question and what the question is asking. 2. Generally, an assessment of the client occurs before an action is taken. 3. Identify the least invasive intervention before taking action. 4. Have all the necessary information and take all possible relevant actions before calling the physician or health care provider. 5. Determine which client to assess first (e.g., most at risk, most physiologically unstable). 6. Identify opposites in the answers. a. Example: prone/supine; elevated/decreased b. Read VERY carefully; one is likely to be the answer, BUT not always. c. If you do not know the answer, choose the most likely of the “opposites” and move on. 7. Take into account a client’s lifestyle, culture, and spiritual beliefs when answering a question. C. Use CRITICAL THINKING, reasoning, and common sense to answer questions. 1. DO respond based on… a. Client safety b. ABCs c. CAB for CPR d. Caring e. Incorporation of culture and spiritual practices f. Scientific, behavioral, and sociologic principles g. Communication (spoken and written, e.g., documentation) with client, family, and colleagues and other health care professionals h. Principles of teaching/learning i. Maslow’s hierarchy of needs j. Nursing process k. What’s in the stem: no more, no less (do not read more into the question than is already there). l. NCLEX-RN ideal hospital m. Basic anatomy and physiology 2. DON’T respond based on… a. YOUR past client care experiences or agency b. A familiar phrase or term c. “Of course, I would have already…” d. What YOU think is REALISTIC e. YOUR children, pregnancies, parents, elders, personal response to a drug, etc. f. The “what-ifs” D. Keep memorizing to a minimum. 1. Growth and developmental milestones 2. Death and dying stages 3. Crisis intervention 4. Immunizations schedule 5. Principles of teaching/learning 6. Stages of pregnancy and fetal growth 7. Nurse Practice Act: Standards of Practice and Delegation 8. Ethical practices and standards E. Know commonly used laboratory ranges (Appendix A), what variations mean, and the BEST nursing actions. 1. Hemoglobin and hematocrit (H&H) 2. White blood cells (WBCs), red blood cells (RBCs), platelets 3. Electrolytes: K+, Na+, Ca++, Mg++, Cl– , 4. Blood urea nitrogen (BUN) and creatinine 5. Relationship of Ca++ and 6. Arterial blood gases (ABGs); 7. SED rate, erythrocyte sedimentation rate (ESR), prothrombin time (PT), international normalized ratio (INR), partial thromboplastin time (PTT; see aPTT), activated partial thromboplastin time: seconds (aPTT) (don’t get them confused) F. Nutrition 1. Know commonly used nutrition information. a. High or low Na+ b. High or low K+ c. High d. Iron e. Vitamin K f. Proteins g. Carbohydrates h. Fats 2. Foods and diets related to a. Gastrointestinal/genitourinary disturbances b. Chemotherapy diets and restrictions c. Pregnancy and fetal growth needs d. Dialysis e. Burns 3. Remember concepts a. Introducing one food at a time (infants, allergies) b. Progression “AS TOLERATED” (What nursing assessment guides decisions regarding progression?) G. Medications—SAFE medication administration is more than just knowing the name, classification, and action of the medication. 1. “Six Rights,” including techniques of skill execution 2. Drug interactions 3. Vulnerable organs a. What to assess b. Which laboratory values relate to specific organs 4. Allergies 5. Presence of suprainfections 6. Concepts of peak and trough 7. How you would know a. The drug is working b. There’s a problem 8. Nursing actions 9. Client education should include a. Safety b. Empowerment c. Compliance The NCLEX-RN Licensing Examination A. The main purpose of a licensing examination like the NCLEX-RN is to protect the public. B. The NCLEX-RN 1. Was developed by the National Council of State Boards of Nursing (the Council; this abbreviation is used to refer to the NCSBN throughout this book) 2. Is administered by the State Board of Nurse Examiners 3. Is designed to test candidates’ a. Capabilities for safe and effective nursing practice b. Essential entry-level nursing knowledge HESI Hint The Council wants to ensure that the licensing examination measures current entry-level nursing behaviors. For this reason, job analysis studies are conducted every 3 years. These studies determine how frequently various types of nursing activities are performed, how often they are delegated, and how critical they are to client safety, with criticality given more value than frequency. Job Analysis Studies A. Essential knowledge is determined by job analysis studies. B. Job analysis studies indicate that newly licensed registered nurses are using all five categories of the nursing process and that such use is evenly distributed throughout the five nursing process areas. Therefore equal attention is given to each part of the nursing process in selecting test items (Table 1-1). Nursing Diagnoses A. Nursing diagnoses are formulated during the analysis portion of the nursing process. They give form and direction to the nursing process, promote priority setting, and guide nursing actions (Table 1-2). B. To qualify as a nursing diagnosis, the primary responsibility and accountability for recognition and treatment rest with the nurse. C. The National Conference of the North American Nursing Diagnosis Association (NANDA) provided the following definition of a nursing diagnosis: “Nursing diagnosis is a clinical judgment about individual, family, or community responses to actual and potential health problems/life processes. Nursing diagnoses provide the basis for selection of nursing interventions to achieve outcomes for which the nurse is accountable” (Box 1-1). NCLEXRN does not use NANDA; however, NANDA is used in this book to provide a guide in the formulation and development of the nursing process. TABLE 1-1 The Nursing Process TABLE 1-2 Components of a Nursing Diagnosis D. NCLEX-RN questions regarding nursing diagnosis can take several forms: 1. You may be given the nursing diagnosis in the stem and asked to select an appropriate nursing intervention based on the stated nursing diagnosis. 2. You may be asked to select, from among the choices provided, the most appropriate nursing diagnosis(es) for the described case. B O X 1 - 1 N A N D A - A p p r o v e d N u r s i n g D i a g n o s e s A Activity/Risk for activity intolerance Ineffective airway clearance Risk for allergy response Anxiety Risk for aspiration Risk for impaired attachment B Disorganized infant behavior (Risk for) Risk for bleeding Risk for unstable blood glucose level Disturbed body image Risk for imbalanced body temperature Ineffective breastfeeding Ineffective breathing pattern C Decreased cardiac output Caregiver role strain (risk for) Ineffective childbearing process Impaired comfort Impaired verbal communication Acute confusion (risk for) Chronic confusion Risk for contamination Ineffective coping Compromised family coping D Death anxiety Risk for Sudden Infant Death Syndrome Decisional conflict Risk for delayed development E Risk for electrolyte imbalance Disturbed energy field Impaired environmental interpretation F Adult failure to thrive Dysfunctional family process Fluid volume deficit (risk for) Excess fluid volume G Impaired gas exchange Dysfunctional gastrointestinal motility Grieving/risk for complicated grieving Delayed growth and development H Risk-prone health behavior Ineffective health maintenance Hopelessness Hypothermia/Hyperthermia I Ineffective impulse control Bowel incontinence Urinary incontinence Risk for infection Decreased intracranial adaptive capacity J Neonatal jaundice (risk for) K Deficient knowledge M Risk for disturber maternal-fetal dyad Impaired memory Impaired physical mobility Moral distress N Nausea Unilateral neglect Imbalanced nutrition: less than body requirements O Impaired oral mucous membrane P Acute/Chronic pain Impaired parenting Disturbed personal identity Risk for poisoning Posttrauma syndrome (risk for) Powerlessness (risk for) R Rape-trauma syndrome Impaired religiosity HESI Hint A nursing diagnosis must be subject to oversight by nursing management. It is not a medical diagnosis. The cause may or may not arise from a medical diagnosis. Risk for ineffective renal perfusion Impaired individual resilience Parental role conflict Ineffective role performance S Chronic low self esteem Self-mutilation Sexual dysfunction Social isolation Risk for suicide T Ineffective thermal regulation Impaired tissue integrity Ineffective peripheral tissue perfusion Risk for decreased cardiac tissue perfusion Risk for ineffective cerebral tissue perfusion Risk for trauma U Impaired urinary elimination Urinary retention V Risk for vascular trauma Impaired spontaneous ventilation Dysfunctional ventilatory weaning response Risk for other directed violence W Impaired walking Wandering 3. You may be asked to choose, from four nursing diagnoses, the one that should have priority based on the data in the stem. Client Needs A. Job analysis studies have identified categories of care provided by nurses called client needs. The test plan is structured according to these categories (Table 1-3). Prioritizing Nursing Care A. Many NCLEX-RN test items are designed to test your ability to set priorities—for example: 1. Identify the most important client needs. 2. Which nursing intervention is most important? 3. Which nursing action should be done first? 4. Which response is best? B. Setting priorities 1. What should be done first or next? Remember, client safety is paramount. 2. Those taking the NCLEX-RN should “remember Maslow” (Table 1-4). 3. The Five Rights of Delegation (see Chapter 2, p. 16) HESI Hint Answering NCLEX-RN questions correctly often depends on setting priorities properly, on making judgments about priorities, and on analyzing the case and formulating a decision about care (or the correct response) based on priorities. Using Maslow’s hierarchy of needs can help you to set priorities. The NCLEX-RN Computer Adaptive Testing A. Computer adaptive testing (CAT) is used for implementation of the NCLEX-RN. B. The CAT is administered at a testing center selected by the Council. C. Pearson VUE is responsible for adapting the NCLEX-RN to the CAT format, processing candidate applications, and transmitting test results to its data center for scoring. D. The testing centers are located throughout the United States. E. The Council generates the NCLEX-RN test items. The Way It Works A. The NCLEX-RN consists of 75 to 265 multiple-choice or alternative-format questions (15 of which are “pilot items”) presented on a computer screen. TABLE 1-3 Components of the NCLEX-RN® Test Plan TABLE 1-4 Maslow’s Hierarchy of Needs Need Definition Nursing Implications Physiologic Biologic needs for food, shelter, water, sleep, oxygen, sexual expression The priority biologic need is breathing (i.e., an open airway). Review Table 1-3, which lists activities associated with physiologic integrity. If you were asked to identify the most important action, you would identify needs associated with physiologic integrity (e.g., providing an open airway) as the most important nursing action. Safety Avoiding harm; attaining security, order, and physical safety Review Table 1-3, which lists the activities associated with a safe and effective care environment. Ensuring that the client’s environment is safe is a priority (e.g., teaching an older client to remove throw rugs that pose a safety hazard when ambulating would have a greater priority than teaching him or her how to use a walker). The first priority is safety, then coping skills. Love and belonging Esteem and recognition Giving and receiving affection; companionship; and identification with a groupSelf-esteem and respect of others; success in work; prestige Although these needs are important (described in Table 1-3), they are less important than physiologic or safety needs. For example, it is more important for a client to have an open airway and a safe environment for ambulating than it is to assist him or her to become part of a support group. However, assisting the client in becoming a part of a support group would have higher priority than assisting him or her in developing self-esteem. The sense of belonging would come first, and such a sense might help in developing self-esteem. Selfactualization Aesthetic Fulfillment of unique potential Search for beauty and spiritual goals It is important to understand the last two needs in Maslow’s hierarchy. They could deal with client needs associated with health promotion and maintenance, such as continued growth and development and self-care, as well as those associated with psychosocial integrity. However, you will probably not be asked to prioritize needs at this level. Remember, it is the goal of the Council to ensure safe nursing practice, and such practice does not usually deal with the client’s selfactualization or aesthetic needs. B. The candidate is presented with a test item and possible answers. C. If the candidate answers the question correctly, a slightly more difficult item will follow, and the level of difficulty will increase with each item until the candidate misses an item. D. If the candidate misses an item, a slightly less difficult item will follow, and the level of difficulty will decrease with each item until the candidate has answered an item correctly. E. This process will continue until the candidate has achieved a definite pass or a definite fail score. There will be no borderline pass or fail scores because the adaptive testing method determines the candidate’s level of performance before she or he has finished the examination. F. The fewest number of items a candidate can answer to complete the examination is 75; 15 of them will be pilot HESI Hint One or more of the choices are likely to be very wrong. You usually will be able to rule out two of the four choices rather quickly. Reread the question and choices again if necessary. Ask yourself which choice answers the question being asked. Even if you have absolutely no idea what the correct answer is, you will have a 50/50 chance of guessing the right answer if you follow this process. Your first response will provide an educated guess and will usually be the correct answer. Go with your gut response! Pace yourself from the beginning of the test. Allow approximately 1.5 minutes per question. The NCSBN Candidate Bulletin is available at . Then select: Examinations/Candidates/Basic Information/Bulletin. items and will not count toward the pass or fail score; 60 of them will determine the candidate’s score. G. The number of the item the candidate is currently answering will appear on the upper-right area of the screen. H. When the candidate has answered enough items to determine a definite pass or fail score, a message will appear on the screen notifying the candidate that he or she has completed the examination. I. The most number of items a candidate can answer is 265, and the longest amount of time the candidate can take to complete the examination is 6 hours. J. Candidates will have up to 6 hours to complete the NCLEX-RN examination; total examination time includes a short tutorial, two preprogrammed optional breaks, and any unscheduled breaks they may take. The first optional break is offered after 2 hours of testing. The second optional break is offered after 3.5 hours of testing. The computer will automatically tell candidates when these scheduled breaks begin. 1. All breaks count against testing time. 2. When candidates take breaks, they must leave the testing room, and they will be required to provide a palm vein scan before and after the breaks. K. If a candidate has not obtained a pass/fail score at the end of the 6 hours and has not completed all 265 items in the 6-hour limit but has answered all of the last 60 questions presented correctly, he or she will pass the examination. L. If a candidate has not obtained a pass/fail score at the end of the 6 hours, has not completed all 265 items in the 6-hour limit, and has not answered correctly all of the last 60 questions presented, he or she will fail the examination. M. A specific passing score is recommended by the Council. All states require the same score to pass, so that if you pass in one state, you are eligible to practice nursing in any other state. However, states do differ in their requirements regarding the number of times a candidate can take the NCLEX-RN. N. Although the Council has the ability to determine a candidate’s score at the time of completion of the examination, it has been decided that it would be best for candidates to receive their scores from their individual Board of Nurse Examiners. The Council does not want the testing center to be in a position of having to deal with candidates’ reactions to scores, nor does the Council want those waiting to take their examinations to be influenced by such reactions. O. You must answer each question in order to proceed. You cannot omit a question or return to an item presented earlier. There is no going back; this works in your favor! P. The examination is written at a tenth-grade reading level. Q. There is no penalty for guessing; with four choices, you have a 25% chance of guessing the correct answer. Examination Item Formats A. A number of different types of examination items are presented on the NCLEX-RN examination. The majority of the questions are multiple-choice items with four answers from which the candidate is asked to choose one correct answer. Other format (item types) include: 1. Multiple-response items require the candidate to select one or more responses. The item will instruct the candidate to choose/select all that apply. 2. Fill-in-the-blank questions require the candidate to calculate the answer and type in numbers. A drop-down calculator is provided. 3. Hot-spot items require the candidate to identify an area on a picture or graph and click on the area. 4. Chart or exhibit formats present a chart or exhibit that the candidate must read to be able to solve the problem. 5. Drag-and-drop items require a candidate to rank order or move options to provide the correct order of actions or events. 6. Audio format items require the candidate to listen to an audio clip using headphones and then select the correct option that applies to the audio clip. 7. Graphic format items require the candidate to choose the correct graphic option in response to the question. B. There is no set percentage of alternative items on the NCLEX-RN examination. All examination items are scored either right or wrong. There is no partial credit in scoring any examination questions. HESI Hint The night before taking the NCLEX-RN, allow only 30 minutes of study time. This 30-minute period should be designated for review of test-taking strategies only. Practice these strategies with various practice test items if you wish (for 30 minutes only; do not take an entire test). Spend the night before the examination doing something you enjoy, something that promotes stress reduction, something that does not involve alcohol or other mind-altering drugs. Only you can identify the special something that will work for you. Remember, you can be successful! Gentle Reminders of General Principles Take care of yourself. Follow these golden rules for NCLEX-RN success. A. Eat well: Consume lots of fresh fruits, vegetables, and lean protein and avoid high-fat foods. B. Sleep well: Get a good night’s sleep the night before the test. This is not the time to cram or to party. You have done your job. Now enjoy the process. C. Eliminate alcohol and other mind-altering drugs: It goes without saying that such substances can inhibit your performance on the examination. D. Schedule study time: Between now and the examination, review nursing content, focusing on areas that you have identified as your weak points when taking the practice tests (review your computer scoring sheets). Use a study schedule to block out the time needed for study. Then be good to yourself, and use that blocked time for yourself: study. E. Be prepared: Assemble all necessary materials the night before the examination (admission ticket, directions to the testing center, identification, money for lunch, glasses or contacts). 1. Approved items: Candidates are allowed to bring only identification forms into the testing room. Watches, candy, chewing gum, food, drinks, purses, wallets, pens, pencils, beepers, cellular phones, Post-It notes, study materials or aids, and calculators are not allowed. A test administrator will provide each candidate with an erasable note board that may be replaced as needed while testing. Candidates may not take their own note boards, scratch paper, or writing instruments into the examination. A calculator on the computer screen will be available for use. 2. Allow plenty of time: Arrive early; it is better to be early than late. Allow for traffic jams and so forth. The candidate may want to consider spending the night in a hotel or motel near the testing center the night before the examination. 3. Dress comfortably: Dress in layers so that you can take off a sweater or jacket if you become too warm or wear it if you become too cold. F. Avoid negative people: From now until you have completed the examination, stay away from those who share their anxieties with you or project their insecurities onto you. Sometimes this is a fellow classmate or even your best friend. The person will still be there when the examination is over. Right now you need to take care of yourself. Avoid the negative; look for the positive. G. Do not discuss the examination: Avoid talking about the examination during breaks and while waiting to take the examination. H. Avoid distractions: Take earplugs with you and use them if you find that those around you are distracting you, such as, rattling paper or getting up to leave the examination. I. Think positively: Use the affirmation “I am successful.” Obtain a relaxation and affirmation tape and use it at your hour of sleep PRN (as needed) from now until you take the examination. Use the relaxation tape at night (not on the way to the examination or during breaks while taking the examination; you might fall asleep!). Use the affirmation on the way to the examination or any time you feel the need to boost your confidence. Think, “I have the knowledge to successfully complete the NCLEX-RN.” For more review, go to 2 Leadership and Management Legal Aspects of Nursing Laws Governing Nursing A. Nurse Practice Acts provide the laws that control and regulate the nursing practice in each state to protect the public from harm. Mandatory Nurse Practice Acts authorize that, under the law, only licensed professionals can practice nursing. All states now have mandatory Nurse Practice Acts. Laws affecting nursing practice vary from state to state. B. Nurse Practice Acts govern the nurse’s responsibility in making assignments. Each state sets its own educational and examination requirements. 1. Assignments should be commensurate with the nursing personnel’s educational preparation, skills, experience, and knowledge. 2. The nurse should supervise the care provided by nursing personnel for which he or she is administratively responsible. 3. Sterile or invasive procedures should be assigned to or supervised by a registered nurse (RN). 4. Documentation is a legal and professional requirement that includes electronic medical records and other notations placed in a client’s medical record. Torts (Violation of Client’s Private Right) Description: An act involving injury or damage to another (except breach of contract) resulting in civil liability (i.e., the victim can sue) instead of criminal liability (see Crime). Unintentional Torts A. Negligence and malpractice 1. Negligence: Performing an act that a reasonable and prudent person would not perform. The measure of negligence is “reasonableness” (i.e., would a reasonable and prudent nurse act in the same manner under the same circumstances?). That is, did the nurse provide care that did not meet the standard? 2. Malpractice: Negligence by professional personnel (e.g., professional misconduct or unreasonable lack of skill in carrying out professional duties). Malpractice is a negligent act performed by an individual in a professional role that results in an INJURY. B. Four elements are necessary to prove malpractice; if any one element is missing, malpractice cannot be proved. 1. Duty: Obligation to use due care (what a reasonable, prudent nurse would do); failure to care for and/or to protect others against unreasonable risk. The nurse must anticipate foreseeable risks. Example: If a floor has water on it, the nurse is responsible for anticipating the risk for a client’s falling. 2. Breach of duty: Failure to perform according to the established standard of conduct in providing nursing care. 3. Injury/damages: Failure to meet the standard of care, which causes actual injury or damage to the client (physical injury). Neither emotional nor mental injury is enough to prove malpractice, either physical or mental. 4. Causation: A connection exists between conduct and the resulting injury, referred to as proximate cause or remoteness of damage. C. Hospital policies provide a guide for nursing actions. They are not laws, but courts generally rule against nurses who have violated the employer’s policies. Hospitals can be liable for poorly formulated or poorly implemented policies. Nurses can avoid negligence and malpractice by following the organization policies and procedures. D. Incident reports alert administration to possible liability claims and the need for investigation; they do not protect against legal action being taken for negligence or malpractice. E. Examples of negligence or malpractice: 1. Burning a client with a heating pad 2. Leaving sponges or instruments in a client’s body after surgery 3. Performing incompetent assessments 4. Failing to heed warning signs of shock or impending myocardial infarction 5. Ignoring signs and symptoms of bleeding 6. Forgetting to give a medication or giving the wrong medication Intentional Torts A. Assault and battery 1. Assault: Mental or physical threat (e.g., forcing [without touching] a client to take a medication or treatment) 2. Battery: Actual and intentional touching of one another, with or without the intent to do harm (e.g., hitting or striking a client). If a mentally competent adult is forced to have a treatment he or she has refused, battery occurs. B. Invasion of privacy: Encroachment or trespassing on another’s body or personality 1. False imprisonment: Confinement without authorization 2. Exposure of a person: Exposure or discussion of a client’s case. After death, a client has the right to be unobserved, excluded from unwarranted operations, and protected from unauthorized touching of the body. 3. Defamation: Divulgence of privileged information or communication (e.g., through charts, conversations, or observations) C. Fraud: Illegal activity and willful and purposeful misrepresentation that could cause, or has caused, loss or harm to a person or property. Examples of fraud include: 1. Presenting false credentials for the purpose of entering nursing school, obtaining a license, or obtaining employment (e.g., falsification of records) 2. Describing a myth regarding a treatment (e.g., telling a client that a placebo has no side effects and will cure the disease, or telling a client that a treatment or diagnostic test will not hurt, when indeed pain is involved in the procedure) Crime A. An act contrary to a criminal statute. Crimes are wrongs punishable by the state and committed against the state, with intent usually present. The nurse remains bound by all criminal laws. B. Commission of a crime involves the following behaviors: 1. A person commits a deed contrary to criminal law. 2. A person omits an act when there is a legal obligation to perform such an act (e.g., refusing to assist with the birth of a child if such a refusal results in injury to the child). 3. Criminal conspiracy occurs when two or more persons agree to commit a crime. 4. Assisting or giving aid to a person in the commission of a crime makes that person equally guilty of the offense (awareness must be present that the crime is being committed). 5. Ignoring a law is not usually an adequate defense against the commission of a crime (e.g., a nurse who sees another nurse taking narcotics from the unit supply and ignores this observation is not adequately defended against committing a crime). 6. Assault is justified for self-defense. However, to be justified, only enough force can be used to maintain selfprotection. 7. Search warrants are required before searching a person’s property. 8. It is a crime not to report suspected child abuse (i.e., the nurse’s legal responsibility is to report suspected child abuse). Nursing Practice and the Law Psychiatric Nursing A. Civil procedures: Methods used to protect the rights of psychiatric clients. B. Voluntary admission: Client admits himself or herself to an institution for treatment and retains civil rights. C. Involuntary admission: Someone other than the client applies for the client’s admission to an institution. 1. This requires certification by a health care provider that the person is a danger to self or others. (Depending on the state, one or two health care provider certifications are required.) 2. Individuals have the right to a legal hearing within a certain number of hours or days. 3. Most states limit commitment to 90 days. 4. Extended commitment is usually no longer than 1 year. D. Emergency admission: Any adult may apply for emergency detention of another. However, medical or judicial approval is required to detain anyone for observation, diagnosis and treatment for those clients whose behavior is indicative of mental illness manifested in behavior that poses a danger to themselves or others. HESI Hint Often an NCLEX-RN® question asks who should explain and describe a surgical procedure to the client, including both complications and the expected results of the procedure. The answer is the health care provider. Remember that it is the nurse’s responsibility to be sure that the operative permit is signed and is on the chart. It is not the nurse’s responsibility to explain the procedure to the client. The nurse must document that the client was given the information and agreed to it. Length of admission time is based on state laws. 1. A person held against his or her will can file a writ of habeas corpus to try to get the court to hear the case and release the person. 2. The court determines the sanity and alleged unlawful restraint of a person. E. Legal and civil rights of hospitalized clients 1. The right to wear their own clothes and to keep personal items and a reasonable amount of cash for small purchases 2. The right to have individual storage space for one’s own use 3. The right to see visitors daily 4. The right to have reasonable access to a telephone and the opportunity to have private conversations by telephone 5. The right to receive and send mail (unopened) 6. The right to refuse shock treatments and lobotomy F. Competency hearing: Legal hearing that is held to determine a person’s ability to make responsible decisions about self, dependents, or property 1. Persons declared incompetent have the legal status of a minor—they cannot: a. Vote b. Make contracts or wills c. Drive a car d. Sue or be sued e. Hold a professional license 2. A guardian is appointed by the court for an incompetent person. Declaring a person incompetent can be initiated by the state or the family. G. Insanity: Legal term meaning the accused is not criminally responsible for the unlawful act committed because he or she is mentally ill. H. Inability to stand trial: Person accused of committing a crime is not mentally capable of standing trial. He or she: 1. Cannot understand the charge against himself or herself 2. Must be sent to the psychiatric unit until legally determined to be competent for trial 3. Once mentally fit, must stand trial and serve any sentence, if convicted Patient Identification A. The Joint Commission has implemented new patient identification requirements to meet safety goals ( B. Use at least two patient identifiers. Ask the client to tell you his or her name and date of birth (DOB) whenever taking blood samples, administering medications, or administering blood products. C. The patient room number may not be used as a form of identification. Surgical Permit A. Consent to operate (surgical permit) must be obtained before any surgical procedure, however minor it might be. B. Legally, the surgical permit must be: 1. Written 2. Obtained voluntarily 3. Explained to the client (i.e., informed consent must be obtained) HESI Hint Often questions are asked regarding the Good Samaritan Act, which is the means of protecting a nurse when she or he is performing emergency care. C. Informed consent means the procedure and treatment or operation has been fully explained to the client, including: 1. Possible complications, risks, and disfigurements 2. Removal of any organs or parts of the body 3. Benefits and expected results D. Surgery permits must be obtained as follows: 1. They must be witnessed by an authorized person, such as the health care provider or a nurse. 2. They protect the client against unsanctioned surgery, and they protect the health care provider and surgeon, hospital, and hospital staff against possible claims of unauthorized operations. 3. Adults and emancipated minors may sign their own operative permits if they are mentally competent. 4. Permission to operate on a minor child or an incompetent or unconscious adult must be obtained from a legally responsible parent or guardian. The person granting permission to operate on an adult who lacks capacity (e.g., advanced Alzheimer disease or unconscious adult) to understand information about the proposed treatment must be identified in a Durable Power of Attorney or an Advance Health Directive. Consent A. The law does not require written consent to perform medical treatment. 1. Treatment can be performed if the client has been fully informed about the procedure. 2. Treatment can be performed if the client voluntarily consents to the procedure. 3. If informed consent cannot be obtained (e.g., client is unconscious) and immediate treatment is required to save life or limb, the emergency laws can be applied. (See the subsequent section, Good Samaritan Act.) B. Verbal or written consent 1. When verbal consent is obtained, a notation should be made. a. It describes in detail how and why verbal consent was obtained. b. It is placed in the client’s record or chart. c. It is witnessed and signed by two persons. 2. Verbal or written consent can be given by: a. Alert, coherent, or otherwise competent adults b. A parent or legal guardian c. A person in loco parentis (a person standing in for a parent with a parent’s rights, duties, and responsibilities) in cases of minors or incompetent adults C. Consent of minors 1. Minors 14 years of age and older must agree to treatment along with their parents or guardians. 2. Emancipated minors can consent to treatment themselves. Be aware that the definition of an emancipated minor may change from state to state. Emergency Care A. Good Samaritan Act: Protects health care providers against malpractice claims for care provided in emergency situations (e.g., the nurse gives aid at the scene to an automobile accident victim). B. A nurse is required to perform in a “reasonable and prudent manner.” HESI Hint If the nurse carries out a health care provider’s prescription for which he or she is not prepared and does not inform the health care provider of his or her lack of preparation, the nurse is solely liable for any damages. If the nurse informs the health care provider of his or her lack of preparation in carrying out a prescription and carries out the prescription anyway, the nurse and the health care provider are liable for any damages. HESI Hint Assignments are often tested on the NCLEX-RN. The Nurse Practice Acts of each state govern policies related to making assignments. Usually, when determining who should be assigned to do a sterile dressing change, for example, a licensed nurse should be chosen—that is, an RN or licensed practical nurse (LPN) who has been checked off on this procedure. Prescriptions and Health Care Providers A. A nurse is required to obtain a prescription (order) to carry out medical procedures from a health care provider. B. Although verbal telephone prescriptions should be avoided, the nurse should follow the agency’s policy and procedures. Failure to follow such rules could be considered negligence. The Joint Commission requires that organizations implement a process for taking verbal or telephone orders that includes a read-back of critical values. The employee receiving the prescription should write the verbal order or critical value on the chart or record it in the computer and then read back the order or value to the health care provider. C. If a nurse questions a health care provider’s (e.g., physician, advanced practice RN, physician’s assistant, dentist) prescription because he or she believes that it is wrong (e.g., the wrong dosage was prescribed for a medication), the nurse should do the following: 1. Inform the health care provider. 2. Record that the health care provider was informed and record the health care provider’s response to such information. 3. Inform the nursing supervisor. 4. Refuse to carry out the prescription. D. If the nurse believes that a health care provider’s prescription was made with poor judgment (e.g., the nurse believes the client does not need as many tranquilizers as the health care provider prescribed), the nurse should: 1. Record that the health care provider was notified and that the prescription was questioned 2. Carry out the prescription because nursing judgment cannot be substituted for a health care provider’s judgment E. If a nurse is asked to perform a task for which he or she has not been prepared educationally (e.g., obtain a urine specimen from a premature infant by needle aspiration of the bladder) or does not have the necessary experience (e.g., a nurse who has never worked in labor and delivery is asked to perform a vaginal examination and determine cervical dilation), the nurse should do the following: 1. Inform the health care provider that he or she does not have the education or experience necessary to carry out the prescription. 2. Refuse to carry out the prescription. F. The nurse cannot, without a health care provider’s prescription, alter the amount of drug given to a client. For example, if a health care provider has prescribed pain medication in a certain amount and the client’s pain is not, in the nurse’s judgment, severe enough to warrant the dosage prescribed, the nurse cannot reduce the amount without first checking with the health care provider. Remember, nursing judgment cannot be substituted for medical judgment. Restraints HESI Hint Restraints of any kind may constitute false imprisonment. Especially if there is no documentation indicating specific reasons to prevent harm to the client or others. Freedom from unlawful restraint is a basic human right and is protected by law. Use of restraints must fall within guidelines specified by state law and hospital policy. A. Clients may be restrained only under the following circumstances: 1. In an emergency 2. For a limited time 3. For the purpose of protecting the client or others from injury or from harm B. Nursing responsibilities with regard to restraints 1. The nurse must notify the health care provider immediately that the client has been restrained. 2. It is required and imperative that the nurse accurately document the facts and the client’s behavior leading to restraint. C. When restraining a client, the nurse should do the following: 1. Use restraints (physical or chemical) after exhausting all reasonable alternatives. 2. Apply the restraints correctly and in accordance with facility policies and procedures. 3. Check frequently to see that the restraints do not impair circulation or cause pressure sores or other injuries. 4. Allow for nutrition, hydration, and stimulation at frequent intervals. 5. Remove restraints as soon as possible. 6. Document the need for and application, monitoring, and removal of restraints. 7. Never leave a restrained person alone. Health Insurance Portability and Accountability Act of 1996 Congress passed the Health Insurance Portability and Accountability Act of 1996 (HIPAA) to create a national patient-record privacy standard. A. HIPAA privacy rules pertain to health care providers, health plans, and health clearinghouses and their business partners who engage in computer-to-computer transmission of health care claims, payment and remittance, benefit information, and health plan eligibility information and who disclose personal health information that specifically identifies an individual and is transmitted electronically, in writing, or verbally. B. Patient privacy rights are of key importance. Patients must provide written approval of the disclosure of any of their health information for almost any purpose. Health care providers must offer specific information to patients that explains how their personal health information will be used. Patients must have access to their medical records, and they can receive copies of them and request that changes be made if they identify inaccuracies. C. Health care providers who do not comply with HIPAA regulations or make unauthorized disclosures risk civil and criminal