Exam (elaborations) NURS10111

Question 1 A client with a history of major depression established a psychiatric advance directive that was deemed legally valid. The directive specified that the client did not want electroconvulsive therapy (ECT) at any time. The client is legally competent and has expressed a renewed interest in trying ECT. The nurse should anticipate what event? You Selected: • The advance directive may only be overturned by a court order. Correct response: • The client may revoke or amend the terms of the advance directive. Rationale:During times of legal competency, a client may revoke or amend a psychiatric advance directive. The care team cannot make this decision for the client during times of competency. A court order or the appointment of a person with power of attorney is unnecessary. Question 2 A newly-admitted client has told the nurse, "I always take a thyroid pill each morning but I do not think I have been prescribed it here in the hospital." The nurse confirms that the client's medication orders do not include this. What is the nurse's best action? You Selected: • Contact the client's provider, and discuss the fact that the client normally takes thyroid supplements. Correct response: • Contact the client's provider, and discuss the fact that the client normally takes thyroid supplements. Rationale: The nurse's priority action is to make the provider aware of this potential oversight. Family members should not bring medications that have not been prescribed in the hospital. Thyroid supplements should be taken daily. Question 3 A nurse has discovered a colleague pocketing a partial dose of an opioid despite documenting it as a waste. When confronted, the colleague acknowledges the behavior. What is the nurse's best action? You Selected: • Explain to the colleague that this is a serious violation of policy. Correct response: • Report the colleague's actions because of legal and ethical obligations. Rationale: Nurses have a duty to report substance misuse among colleagues. It is appropriate to seeks solutions with the colleague, but the priority is to ensure that the event is not kept a secret between the two nurses. Question 4 The nurse is assessing a client with a history of mental illness who has been brought to the emergency department by first responders. What characteristic of the client's status would most justify involuntary admission? You Selected: • The client demonstrates a serious risk of self-harm. Correct response: • The client demonstrates a serious risk of self-harm. Rationale: Involuntary admission is often prompted by an individual's realistic risk of self-harm. A history of mental illness, lack of support, or history of nonadherence would not provide sufficient legal basis for involuntary admission. Question 5 The pediatric nurse is providing care for an infant who has been diagnosed with respiratory syncytial virus (RSV). What action best prevents the spread of this infectious microorganism? You Selected: • Wear a face mask when in close contact with the client. Correct response: • Wear a face mask when in close contact with the client. Rationale: RSV infection necessitates droplet precautions, including the use of a facemask. Goggles are not normally included in droplet precautions. It is important to educate family members and visitors about the need for hand hygiene, but the similarities and differences between the two different methods of performing hand hygiene are not a priority. Antiviral medications such as ribavirin are not commonly used, and they do not directly prevent the spread of the infection. Question 6 The nurse on a gerontology unit will be admitting several new clients to the unit over the next few hours. There are two shared rooms and one single-client room currently vacant on the unit. Which client should be placed in the single-client room? You Selected: • a previously healthy client who has been diagnosed with delirium of unknown etiology and who is agitated Correct response: • a client who has developed hypokalemia due to Clostridium difficile-related diarrhea Rationale: For reasons of infection control, a client with Clostridium difficile-related diarrhea must be housed in a single room. This infection control measure would supersede the need to accommodate visitors. It is ideal for a client who is agitated to be in a single-client room, but the necessity of infection control would override this factor. Question 7 At the completion of a shift, the nurse is participating in the nursing handoff during the transition from the day shift to the evening shift. At the time of shift change, there are not enough evening nurses to meet mandated nurse-client ratios. What is the nurse's best action? You Selected: • Document the situation, and remain on the unit until sufficient staffing levels are achieved. Correct response: • Document the situation, and remain on the unit until sufficient staffing levels are achieved. Rationale: In order to avoid abandoning clients, the nurse is required in most jurisdictions to remain on the unit until safe staffing levels are achieved. Careful documentation is necessary during all stages of such as transition. Question 8 A client has sought care because she has recently returned from a trip to Central and South America and is concerned that she might have contracted the Zika virus. What question should the nurse prioritize during the client interview? You Selected: • "Were you vaccinated against the Zika virus before you left on your trip?" Correct response: • "Is there any chance that you might be pregnant?" Rationale: Infection with the Zika virus is associated with an increased risk of microcephaly. There is no vaccine, and it is spread by mosquitos; being on a farm or ranch is not a risk factor. The client's overall level of health is important during any assessment, but this is not directly related to the possibility of Zika virus infection. Question 9 A client is scheduled for a laparoscopic cholecystectomy and is surprised to learn that he will be discharged later the same day, provided there are no complications. When caring for a client who will be discharged shortly after a procedure, the nurse must: You Selected: • ensure that the client is safe to drive before being discharged. Correct response: • ensure that health education is begun as early as possible. Rationale: Trends towards early hospital discharge heighten the need to begin health education as early as possible and to reinforce it often. Clients cannot drive themselves home safely on the day of surgery, and it is not the nurse's responsibility to review the specific provisions of informed consent documentation. Antibiotics will be prescribed on a case by case basis; their use and the timing of administration will vary. Question 10 A client is has presented to the emergency department with symptoms that are suggestive of appendicitis. The client admits to the nurse, "I am very nervous because I am in the country illegally and have been for several years." What is the nurse's best response? You Selected: • "We are going to give you the treatment you need. The care team does not involve ourselves with your immigration status." Correct response: • "We are going to give you the treatment you need. The care team does not involve ourselves with your immigration status." Rationale: A client's immigration status is highly significant, but this variable is not the responsibility of the nurse and the other members of the healthcare team. A nurse should never counsel a client towards secrecy. Question 11 A client's spouse has expressed great concern about the fact that antibiotics have been prescribed for the treatment of pneumonia. The spouse states, "I do not trust all these pharmaceuticals. We are going to treat the pneumonia using the magnet therapy I read about online." What is the nurse's best response? You Selected: • "It sounds like you have got some important questions about the treatment plan and the use of medication. Could we talk about them?" Correct response: • "It sounds like you have got some important questions about the treatment plan and the use of medication. Could we talk about them?" Rationale: When clients present information that is inaccurate or unfounded, the nurse should use this opportunity to discuss the client's doubts and reservations. A confrontational or condescending approach is disrespectful and is unlikely to have the desired effect. Question 12 A child has been brought to the emergency department by child's grandparent. The grandparent tells the nurse, "It is important that the child's parents not know she is here. She lives with me, and they are no good for her." What is the nurse's most relevant assessment question? You Selected: • "Do you have legal custody of the child?" Correct response: • "Do you have legal custody of the child?" Rationale: In addition to enlisting other members of the care team, the nurse must know whether the grandparent has legal custody of the child or if the parents still have custody. This information must be known in order to manage this situation and before the other assessment questions can be addressed. Question 13 The nurse is performing a prenatal assessment of a client who is in her first trimester. The client states, "I have heard horrible things about the Zika virus and pregnancy. It makes me so worried about my baby." What is the nurse's most relevant assessment question? You Selected: • "Have you traveled recently?" Correct response: • "Have you traveled recently?" Rationale: Zika virus has not been locally acquired in North America. A client who has not traveled in the recent past would be highly unlikely to be infected. For this reason, questions about travel would be prioritized over questions about symptoms. The client's medication history is not relevant. Question 14 A client was admitted to the coronary care unit (CCU) two days ago with an acute myocardial infarction. Which action would breach client confidentiality? You Selected: • The emergency department (ED) nurse calls up the latest electrocardiogram results to check the client’s progress. Correct response: • The emergency department (ED) nurse calls up the latest electrocardiogram results to check the client’s progress. Rationale: The ED nurse is no longer directly involved with the client’s care, and has no legal right to information about his present condition. Anyone directly involved in his care (such as the telemetry nurse and the on-call provider) has the right to information about his condition. Because this client asked the nurse to update his wife, doing so doesn’t breach confidentiality. Question 15 A client’s family just completed a care conference with the health care team. The family has decided to withdraw treatment. What is the nurse’s next step? You Selected: • Document the decision in the client’s electronic record. Correct response: • Document the decision in the client’s electronic record. Rationale: After a decision has been made, the nurse should document the decision in the client’s electronic record. This will alert additional members of the health care team. The client should not be transferred to a different floor. The pharmacy will receive notification from the EMR. Family members should communicate to others about the decision. The nurse should be caring for the client. Question 16 A nurse completes an afternoon assessment of a client who is a nurse and who is visiting the area on vacation. The client states that the nurse must be having a busy shift and asks about the maximum number of clients that the nurse is allowed to care for. What is the nurse's best response? You Selected: • “Some jurisdictions have staffing laws which allow for nurses to be involved in staffing ratios.” Correct response: • “Some jurisdictions have staffing laws which allow for nurses to be involved in staffing ratios.” Rationale: Staffing laws exist in some jurisdiction, but not others. Staffing laws tend to fall into one of three general approaches: The first is to require hospitals to have a nurse driven staffing committee which create staffing plans that reflect the needs of the patient population and match the skills and experience of the staff. The second approach is for legislators to mandate specific nurse to patient ratios in legislation or regulation. A third approach is requiring facilities to disclose staffing levels to the public and/or a regulatory body. A facility is required to disclose staffing levels to the public. Question 17 A nurse is discussing wound care with a client. The client insists on taking a short video of the instruction by using the client's smart phone. What is the nurse’s best response to the client? You Selected: • “Let me check with the hospital policy regarding making a video.” Correct response: • “Let me check with the hospital policy regarding making a video.” Rationale: Use of technology and use of social media should be reviewed with the client. The institution may have a policy regarding what can and cannot be used. Question 18 Which question has been added to nursing admission assessment to screen for the Zika virus? You Selected: • Have you recently traveled to Africa? Correct response: • Have you recently traveled to South America? Rationale: Central and South America are areas experiencing the transmission of the Zika virus. Question 19 Which questions have been added to nursing admission assessment to screen for the Ebola virus? Select all that apply. You Selected: • Are your vaccinations up to date and have you followed the CDC recommendations for vaccinations? • Are you a resident of or have you traveled within the last 21 days to a country where an Ebola outbreak is occurring? • Have you been exposed to someone who is suspected or known to have Ebola? Correct response: • Are you a resident of or have you traveled within the last 21 days to a country where an Ebola outbreak is occurring? • Have you been exposed to someone who is suspected or known to have Ebola? Rationale: Asking if the client has Ebola is not part of the screening program. Ebola cannot be prevented by immunizations. Question 20 A client is recovering from a bacterial infection with intravenous antibiotics. The healthcare team is planning for the client to be discharged tomorrow. However, the client wants to leave today because the client’s animals do not have someone to feed them tomorrow. What is the nurse’s best response to this client? You Selected: • “You have a right to leave early, but let us make sure you are aware of all the complications that can occur.” Correct response: • “You have a right to leave early, but let us make sure you are aware of all the complications that can occur.” Rationale: The client does have the right to leave against medical advice (AMA). Imperative to AMA, the nurse should counsel the client regarding the potential complications related to the discharge. The client also needs to sign the paperwork, and the nurse needs to be aware of this. Question 21 A nurse is preparing a 24-hour-old baby boy for circumcision. The hospital policy guidelines for circumcision support pain medication at least 1 hour prior to the start of the procedure. The provider did not order the pain medication. The provider arrives, and the nurse refuses to bring the baby for the circumcision stating that the pain medication was not ordered. Which is the rationale for refusing to bring the baby for the procedure? You Selected: • A nurse has a right to refuse orders that they believe will be harmful to the client. Correct response: • A nurse has a right to refuse orders that they believe will be harmful to the client. Rationale: The nurse does have a right to refuse orders if they believe it will be harmful to the client. The nurse practice act of each state governs the practice of nursing. Each nurse should have a copy of the state practice act, the regulations, and any other official documents governing nursing practice for each state where he or she is employed. All of these documents define the legal scope of nursing practice and guide and protect nurses in performing their duties. Question 22 A female client enjoys wearing men’s clothing. Her sister tells the nurse that the client would like to have gender reassignment surgery. The client tells the nurse that she just wants to be left alone. Which nursing intervention should the nurse take first? You Selected: • Encourage the client to change her clothes Correct response: • Inform the client’s sister of medical privacy laws Rationale: The client’s sister must understand that her sister’s health care is private and cannot be discussed with her. The client needs to verbalize her feelings regarding wearing male attire, as well as her desire to be left alone. Telling the client that she is repressing her true feelings is judgmental. It’s inappropriate for a nurse to have the client change her clothes for no safety or therapeutic reason, or to advise the client to avoid her sister. Question 23 A nurse admitted a client with ulcerative colitis. A case manager is visiting the client and wants to discuss care. What is the nurse’s understanding of the case manager? You Selected: • The case manager is aware of all needs of the client during the hospitalization and provides them after the client returns home. Correct response: • The case manager collaborates care among all health care partners with the client in the center. Rationale: Case management is a collaborative process. They work closely with physicians, nurses, social workers, and a wide range of medical and nonmedical professionals. Case managers work to meet complex patient needs. They make provisions for current and future needs of patients. Case management nurses promote quality care which encourages appropriate use of available resources. Question 24 A client just delivered a healthy baby. The mother wants to put photos on her Facebook page with all the nurses that helped during the birthing process. What is the nurse’s response to the client? You Selected: • “I will have to check with the hospital policy about posting nurses to the Facebook page.” Correct response: • “I will have to check with the hospital policy about posting nurses to the Facebook page.” Rationale: Nurses should be aware of the hospital policy regarding health care personnel and clients. If the policy allows photos, then the other responses are appropriate. Question 25 A client is prescribed a newer oral diabetic medicine. The client returns for a follow-up visit and starts to describe a variety of ailments the client had with the medicine. The nurse questions the client and asks where the client obtained the information. The client says that the client read a daily blog about the medication on the internet and all the bloggers complained of the same symptoms. Which statement is important for the nurse to include in teaching about the medication? You Selected: • Reliable sources of information, such as one's prescriber and the CDC, are encouraged. Correct response: • Reliable sources of information, such as one's prescriber and the CDC, are encouraged. Rationale: The client should be referred to the prescriber. In addition, the client should be taught that reliable sources on the internet provide accurate medical information such as the CDC. Blogs are great ways to discuss issues but they are not a reliable source of information. Question 26 A health care provider is legally and ethically required to disclose certain information. Which confidential information should the nurse disclose? You Selected: • A taxi driver’s diagnosis of an uncontrolled seizure disorder to his licensing agency Correct response: • A taxi driver’s diagnosis of an uncontrolled seizure disorder to his licensing agency Rationale: The health care provider may lawfully disclose confidential information about a client when the welfare of others is at stake. The health care provider is required to inform the Department of Motor Vehicles that the taxi driver has an uncontrolled seizure disorder because it’s in the best interest of the public’s and client’s safety. Confidentiality of HIV testing is required. Disclosing a client’s cancer diagnosis to a significant other or pregnancy to a legally separated partner do not affect the welfare of person. Question 27 A male client with a terminal illness is unconscious. His wife wants his status to be full code. His sister, who is the durable power of attorney and healthcare proxy, insists that his status should be do not resuscitate (DNR). Which person has legal precedence? You Selected: • The sister’s wishes are legally binding. Correct response: • The sister’s wishes are legally binding. Rationale: The durable power of attorney for health care takes legal precedence. It is often recommended that this role be given to someone objectively distanced from the client. Question 28 The home health nurse is assessing a client and determines that she has an unsteady gait. The client tells the nurse that she has a history of falls. Which nursing action represents an advocacy role for the home health nurse? You Selected: • Contacting a health care equipment resource to rent a walker for the client to use Correct response: • Contacting a health care equipment resource to rent a walker for the client to use Rationale: Referral to community agencies is an advocacy role for home health nurses. The role of the advocate implies the home care nurse is able to advise clients how to find alternative sources of care. Giving emotional support, giving therapies to clients, and instructing clients about other resources are direct care activities. Reassuring the client is superficial, and using a walker may not prevent falls in the future. Question 29 A nurse who is working with a nursing assistant is making care assignments for the shift. Which task would be most appropriate for the nurse to delegate to the nursing assistant? Select all that apply. You Selected: • assisting with a bed bath for a client who had surgery yesterday • documenting oral intake on the I&O;flow sheet • checking vital signs Correct response: • checking vital signs • documenting oral intake on the I&O;flow sheet • assisting with a bed bath for a client who had surgery yesterday Rationale: When delegating client assignments and tasks, the nurse must make sure that the tasks assigned meet the training and educational level of the person to whom the task was assigned. It would be appropriate for the nurse to assign tasks such as checking vital signs, documenting oral intake, and assisting with hygiene measures. Evaluating a client’s response to pain medication and assessing a client’s bowel sounds are higher level, skilled tasks that the registered nurse must perform. Question 30 A nurse is talking with a client who is terminal. The client tells the nurse, “I have a document that says that my son is the one to make decisions about my health care if I cannot. This form should be on my chart.” When reviewing the client’s medical record related to this discussion, the nurse would most likely find a: You Selected: • durable power of attorney for health care. Correct response: • durable power of attorney for health care. Rationale: The client is describing a durable power of attorney for healthcare which appoints an agent the person trusts to make decisions in the event of subsequent incapacity. A living will provides specific instructions about the kinds of healthcare that should be provided or foregone in particular situations. Often these may be combined in one document. A care provider order for life-sustaining treatment (POLST) form is a medical order indicating a patient’s wishes regarding treatments commonly used in a medical crisis. Because it is a medical order, a POLST form must be completed and signed by a healthcare professional and cannot be filled out by a patient. A do-not-resuscitate order means that no attempts are to be made to resuscitate a patient whose breathing or heart stops. This order is written by the primary care provider in consultation with the family. Question 31 A mother brings her newborn in for a well-child check-up. During the visit, the mother tells the nurse that she is concerned about having her baby vaccinated because she heard that vaccinations can cause autism. Which response by the nurse would be most appropriate? You Selected: • “Let us talk about your concerns.” Correct response: • “Let us talk about your concerns.” Rationale: According to the Centers for Disease Control (CDC), there is no link between vaccines and autism, and no evidence exists to support the thinking that vaccine ingredients cause autism. The mother evidently has concerns, and the nurse needs to address the concerns by talking with the mother and providing information to her about the safety of vaccines. Telling the mother that her concern is valid only reinforces the myth and misconception. Telling the mother that the nurse has not heard of any cases is inappropriate and does not address her concern or allow for further discussion. Telling the mother that the nurse will inform the pediatrician is inappropriate because it reinforces the mother’s misconceptions. Question 32 A nurse is providing care to a client with cancer. The client tells that nurse that the care provider is not giving enough information about the client's condition. Which behavior by the nurse demonstrates advocacy? You Selected: • confronting the care provider about why information is not being shared Correct response: • helping the client create a list of questions to ask the care provider Rationale: Advocacy refers to taking the client’s side and supports the client’s right to information necessary to make his or her own decisions. However, sometimes client advocacy conflicts with the care provider’s viewpoint, but the nurse must make sure to maintain a collaborative working relationship with the car provider and not intrude on the care provider-client relationship. In this situation, the nurse demonstrates advocacy by helping the client assert himself by developing a list of questions to ask the care provider. Confronting the care provider would be inappropriate and detrimental to the collaborative relationship. Telling the client the information also violates the care provider-client boundaries and could be detrimental to the collaborative relationship. Advising the client to get a second opinion is inappropriate because it does not address the client’s need for information. Question 33 An infection control nurse has identified a problem related to infection control procedures on a medical unit that has a high census of clients diagnosed with tuberculosis. The nurse has decided to conduct an in-service education program for the staff about the required transmission-based precautions. The nurse determines that the program was successful based on which statement by the staff? You Selected: • “The client needs to be placed in a private, negative air pressure room.” Correct response: • “The client needs to be placed in a private, negative air pressure room.” Rationale: A client with tuberculosis should be on airborne precautions. This includes using a private, negative air pressure room, transporting the client as little as possible, having the client wear a mask if the client is being transported out of the room, removing the respirator after leaving the client’s room, and keeping the client’s room door shut. Question 34 A client who has been treated initially in the emergency department for a leg wound from a fall is waiting for care provider evaluation. The client says, "I am tired of waiting, and I am going to leave." The nurse explains that it is important to wait to ensure that there are no other injuries. The client tells the nurse, “I am going to leave. I am not waiting around here any longer. My leg is fine.” Which response by the nurse would be most appropriate? You Selected: • Give the client permission to leave at any time. Correct response: • Notify the care provider of the client’s intent to leave. Rationale: When a client wants to leave a facility, he or she is legally free to do so, even though such actions carry an increased risk for problems. The nurse has already attempted to explain the importance of staying, so the next step would be to notify the care provider who should then reinforce the need to stay for an evaluation. If the client continues to voice the desire to leave, the client should sign a form that releases the care provider and facility from any legal responsibility for the client’s health status. Calling security to block the client’s exit is inappropriate and would be considered false imprisonment. Warning the client that he or she will be restrained is threatening and also considered false imprisonment. Question 35 A nurse is conducting an educational program about advanced directives for a group of adults at a local community center. The nurse explains what the directives entail and how they are used. After explaining this topic, the nurse determines that the teaching was successful based on which statement by the group? You Selected: • “The document allows us to choose what we want to have happen.” Correct response: • “The document allows us to choose what we want to have happen.” Rationale: An advanced directive allows individuals to state in advance what their choices would be for healthcare should certain circumstances develop. One type, a durable power of attorney can specify an individual of the client’s choosing, not the primary care provider, to make healthcare decisions should the client be incapable of doing so. The directive may or may not identify the use of resuscitative measures. Organ donation may or may not be part of the directive. The client may have a universal organ donor card or, in some states, specify on the driver’s license that the client is an organ donor. Question 36 A nurse is working on a unit that is short staffed for the shift and is delegating client care to a licensed practical nurse. Which activity would be appropriate for the nurse to delegate? Select all that apply. You Selected: • vital sign monitoring of a client who is 3 days postsurgical repair of a fractured hip • administering a sitz-bath to a client who has had perineal surgery 2 days ago • assistance with range of motion exercises for a client diagnosed with Alzheimer’s disease Correct response: • vital sign monitoring of a client who is 3 days postsurgical repair of a fractured hip • assistance with range of motion exercises for a client diagnosed with Alzheimer’s disease • administering a sitz-bath to a client who has had perineal surgery 2 days ago Rationale: The nurse, when delegating tasks, needs to keep in mind the scope of practice for the licensed practical nurse (LPN). Vital sign monitoring, assistance with range of motion exercises, and administering a sitz-bath are within the scope of practice for an LPN. The LPN can collect or gather data and reinforce teaching, but the assessment and education are outside the LPN’s scope of practice. Question 37 The client becomes upset when the nurse asks if the client has an advance directive and states, “Why do I need an advance directive?” What is the most appropriate explanation for the nurse to give this client about an advance directive? You Selected: • “Let’s talk about how an advance directive enables you to have your health care preferences known to your health care providers.” Correct response: • “Let’s talk about how an advance directive enables you to have your health care preferences known to your health care providers.” Rationale: The client’s statement indicates a need to learn the purpose of an advance directive (which is to have the client’s health care preferences made known to the health care providers). Inviting clients to talk about making decisions and stating their wishes about end-of-life care and health care treatment enables the clients to discuss what is important and culturally appropriate to them. An advance directive does not ensure the arrangement of ideal or optimal care in all medical circumstances, but assists the client to select desired care and a health care proxy. It gives the clients a voice in decision making and establishes that their wishes will be followed. Question 38 The client who is four days' post-kidney transplantation tells the nurse, “I feel upset about the person who died to give me this kidney.” Which goal will the nurse consider to be of primaryimportance? You Selected: • Assess the client for feelings of guilt related to the surgery. Correct response: • Encourage the client to talk openly and express feelings. Rationale: It is important for the client to discuss concerns and to express feelings related to the person whose kidney was donated. The nurse’s primary goal is to maintain open communication and encourage the client to address feelings and concerns. The client may be experiencing grief related to the loss of the donor’s life. The expression of feelings will assist the client to cope with them rather than to dwell on negative feelings like guilt. Distractions can provide temporary respite from the anxiety felt. However, it is more therapeutic to have the client express and manage current feelings. The discussion of the client’s concerns about death and dying may be something to address in a future conversation. Question 39 The parent of a client who is disabled due to a traumatic amputation states to the nurse, “I am concerned that situations will occur and that I may not know what to do to help my son when we are at home.” Which response by the nurse is the most appropriate to address the parent’s concern? You Selected: • Talk to your son about what he needs and ask how you can be of assistance. Correct response: • Talk to your son about what he needs and ask how you can be of assistance. Rationale: There will be times where the best strategy for the parent to use is to ask the client what he needs, and request that he identify how the parent can best facilitate assistance and support in that specific situation. Although written information and the creation of a plan of care can be helpful, it is best to provide the parent with a general guideline to use since various situations will not be addressed in these materials. Focusing on the parent’s limitations may limit communication and make the client hesitant to ask for assistance. Question 40 The nurse has taught the wife of a client who experienced traumatic vision loss strategies for effectively interacting with her spouse. Which statement by the wife indicates that the health teaching was successful? You Selected: • “Today I used the clock suggestion to state where things were located in the room.” Correct response: • “Today I used the clock suggestion to state where things were located in the room.” Rationale: If the wife is giving directions by using clock cues, then the teaching has been effective. When the wife unilaterally makes decisions like deciding to obtain a service dog, determining that the spouse must be seated first, and insisting that she guide her husband rather than just offering assistance, then the nurse recognizes that additional teaching is necessary. Question 41 The client expressed to the nurse that she feels guilt and shame for contracting HIV/AIDS from her ex-boyfriend eight years ago, and although she is feeling well, she cannot develop healthy relationships. What priority action will the nurse implement during the client assessment? You Selected: • depression screening Correct response: • depression screening Rationale: The priority screening is for depression, since it frequently occurs in people with HIV/AIDS who experience guilt, sadness, lack of confidence, and a sense of worthlessness. Clients with serious depression are at risk for suicidal ideation and suicidal actions. Any of the other screenings for addiction, anxiety, and cognitive functioning may be useful to perform in the future. Question 42 An 86-year-old client with dementia is being discharged after treatment for a hip fracture. In reviewing the notes, the nurse identifies that the sole care-giver at home is an adult daughter with a moderate intellectual disability. Which is the most important action the nurse should ensure is in place before discharging the client home? You Selected: • An immediate home visit is arranged with the visiting nurse service and the social worker. Correct response: • An immediate home visit is arranged with the visiting nurse service and the social worker. Rationale: The visiting nurse service will be the primary service to coordinate all care in the home after discharge. It will be necessary for them to quickly assess the needs of this family to determine the level of supervision and support they will require. This care may require more than a daily visit, as well as support from a home health aide. Care will necessarily include physical therapy and social work services. If the visiting nurse service determines an increased level of care is required, they will provide the necessary documentation to the client’s health insurance company. Question 43 After being informed that a client is to be admitted to the hospital for stabilization of the client's diabetes, the client's son returns to the hospital six hours later to find that the client remains on a stretcher in the emergency department hallway. He begins to shout “I will not allow my insurance to pay for your failure to provide care.” What is the best action for the nurse to take in this situation? You Selected: • Ensure the comfort and security of the client and meet privately with the family member. Correct response: • Ensure the comfort and security of the client and meet privately with the family member. Rationale: It is imperative to insure that the client who remains in an interim status awaiting admission to a hospital ward bed is safe and comfortable, as well as being reassured that this person is being cared for. The nurse should then meet privately with the family member to address concerns, provide reassurance, answer questions, and provide referrals (to administration or advocacy as may be indicated). It is inappropriate to have the family confronted by security or threatened to be removed. The nurse may contact security as warranted if the family member becomes threatening. Arranging for the client to be moved out of the hallway is a reasonable compromise if this option is, or becomes available. Contacting the nursing supervisor is appropriate, but it is unreasonable to insist that the client be transferred immediately. Question 44 A client is admitted for serious complications of poorly managed diabetes. The nurse learns that this client is an undocumented illegal immigrant whose sole income is sporadic day labor. What is the most important action this nurse should take? You Selected: • Establish rapport with the client to fully assess client needs. Correct response: • Establish rapport with the client to fully assess client needs. Rationale: The nurse’s responsibility is to treat the client and this should begin with establishing a therapeutic relationship and a complete nursing assessment. It is inappropriate to discharge the client, report the client to immigration, or involve social workers at this point. Question 45 A teenage client is to be admitted for a fractured shoulder after being impaled on a fence running away from local police. The nurse learns that the teen lives on the street with surrogate parents. Once the client is assessed and treated, which would be the most appropriate action? You Selected: • Notify the police that the client is being released. Correct response: • Contact social services to advocate for the teen. Rationale: As this client is a minor and was running from the police, it is likely that the teen is a runaway who is not an emancipated teenager. The nurse should recognize that social services is the appropriate first point of contact to advocate on the teen's behalf and coordinate with necessary persons. Based on the information presented, it is inappropriate to notify the police. There is no information suggesting that hospital security should be involved, or that the teen must be escorted from the facility. Arranging visiting nurse services is unhelpful as the teen is homeless. It might be more helpful to refer the client to an area clinic that services the homeless. Question 46 A client is being assessed for multiple lacerations resulting from an assault by an unknown paid sexual partner. The nurse must recognize what as a priority for this client? You Selected: • The client's safety should be provided in a secure and private environment. Correct response: • The client's safety should be provided in a secure and private environment. Rationale: Regardless of the gender of the client or the attacker, a traumatic assault demands that safety and security are a top priority. The client may resist filing a police report because of the paid sex (prostitution), and because it was with a stranger. Testing for sexually transmitted diseases is not a priority until the wounds have been treated. The client’s illicit behavior does not warrant being referred to a community free clinic. Question 47 An HIV-positive client who has been treated with antiretroviral therapy for two decades presents at the emergency department with symptoms typically associated with myocardial infarction. The nurse assessing this client should immediately recognize which factor associated with chronic HIV? You Selected: • Chronic HIV clients are at increased risk for cardiovascular disease. Correct response: • Chronic HIV clients are at increased risk for cardiovascular disease. Rationale: The nurse should recognize that a long-term HIV positive client is at increased risk for many chronic conditions, including cardiovascular disease and myocardial infarction. HIV causes chronic inflammation which can contribute to cardiovascular disease. Some antiretroviral medications are associated with insulin resistance and hyperlipidemia, thus increasing the risk of cardiovascular disease. It is judgmental to assume that this client is a smoker because of his HIV diagnosis. It is not true that either antiretroviral agents protect against cardiovascular disease or that emergency cardiac drugs are contraindicated in clients taking antiretroviral agents. Question 48 A child is brought into the emergency department with a severe asthmatic episode by the grandparents who are caring for the child over the weekend while the parents are away. What is the first priority of the nurse treating this child? Select all that apply. You Selected: • A medical power of attorney for the grandparents signed by the parents is acceptable. • Severe asthmatic episodes can be life threatening and must be treated immediately. Correct response: • Severe asthmatic episodes can be life threatening and must be treated immediately. Rationale: The nurse should acknowledge that life-threatening and emergency care should take priority over legal or administrative tasks. A medical power of attorney for the grandparents signed by the parents is an acceptable substitution for parental permission within the parameters of the signed document (i.e., over the weekend). Delaying emergency treatment until the parents can be reached by any means – even in the absence of a valid power of attorney, is unacceptable practice. Necessary permissions could be obtained as soon as the responsible party can do so. Question 49 A client is undergoing chemotherapy without responding to three different rounds of agents. The client proposes testing for specific serum metal levels based on a review of the history of symptoms and Internet research. The nurse recognizes that the client is demonstrating: You Selected: • self-advocacy Correct response: • self-advocacy Rationale: The client has survived through three rounds of chemotherapy and has now done a health and environmental review to identify a possible complicating factor. Given the presentation, the serum metal levels should be drawn and the ideas should be explored. This client is successfully advocating and demonstrating acceptance of responsibility for a role in the treatment plan. There is no evidence of hopelessness, false hope, or quackery present in the proposal. Question 50 A client with long-term body-focused repetitive behaviors including trichotillomania (hair pulling) finds support through an online website. The client begins to attend local meetings and realizes that a nurse from the clinic also attends. When approached outside of these meetings, how should the nurse respond? You Selected: • Discuss this to define the relationship. Correct response: • Discuss this to define the relationship. Rationale: Social media and self-help groups can contribute to blurred boundaries between personal and professional relationships. The nurse should take the lead to discuss boundaries with the client. This means that the relationship needs to be defined. Generally letting the client do this fails as they do not understand the conflict and respond positively to having contact with their nurse outside of the professional setting. Pretending not to know the client can be hurtful, while leaving the group can be detrimental to the nurse.