A 15-year-old adolescent confides in the nurse that he has been contemplating suicide.
He says he has developed a specific plan to carry it out and pleads with the nurse not to
tell anyone. What is the nurse's best response?
You Selected:
"For your protection, I can't keep this secret. After I notify the physician, we will
need to involve your family. We want you to be safe."
Correct response:
"For your protection, I can't keep this secret. After I notify the physician, we will
need to involve your family. We want you to be safe."
Explanation:
In situations in which a client is a threat to himself, the nurse can't honor confidentiality.
Because this adolescent has said he has a specific plan to commit suicide, the nurse
must take immediate action to ensure his safety. The physician and mental health
professionals should be notified as well as the client's family. The nurse should inform
the adolescent that she must do this, while at the same time conveying a sense of
caring and understanding. The local authorities needn't be notified in this situation.
Remediation:
Question 2 See full question
As a client is being released from restraints, he says, "I'll never get that angry and lose it
again. Those restraints were the worst things that ever happened to me." Which
response by the nurse is most appropriate?
You Selected:
"I'd like to talk with you about your experience."
Correct response:
"I'd like to talk with you about your experience."
Explanation:
After a client is released from restraints, he and the nurse need to process the
experience by discussing why restraints were used and any other information the client
wishes to discuss. Asking the client if he means what he says challenges or questions
the validity of his statement. Simple reflection of the client's words may not open up
discussion about the experience. Telling the client that the experience won't bother him
in the future is judgmental and trivializes the client's remark.
Remediation:
,Question 3 See full question
Which instruction should a nurse include in an injury-prevention plan for a pregnant
client?
You Selected:
"Take rest periods during the day."
Correct response:
"Take rest periods during the day."
Explanation:
The client should be instructed to avoid becoming fatigued and to take rest periods
during the day. Fatigue can lead to injuries. The nurse should instruct the client to wear
a seat belt below the tummy, not across it, and to position the steering wheel toward her
chest, not her abdomen, to prevent injury to the fetus. Learning a new activity or sport
while pregnant can lead to injury.
Remediation:
Question 4 See full question
A client with stage II Alzheimer's disease is admitted to the short stay unit after cardiac
catheterization that involved a femoral puncture. The client is reminded to keep his leg
straight. A knee immobilizer is applied, but the client repeatedly attempts to remove it.
The nurse is responsible for three other clients who underwent cardiac catheterization.
What's the best step the nurse can take?
You Selected:
Ask the staffing coordinator to assign a nursing assistant to sit with the client.
Correct response:
Ask the staffing coordinator to assign a nursing assistant to sit with the client.
Explanation:
The nurse should ask the staffing coordinator to assign a nursing assistant to sit with
the client. This action promotes client safety while avoiding restraint use. Applying wrist
restraints doesn't prevent injury to the lower leg. Also, restraints should be applied only
after other less restrictive measures have been attempted. A client with stage II
Alzheimer's disease has memory impairment that impedes his ability to remember
repeated instruction. Sedation isn't indicated for this client.
Remediation:
Question 5 See full question
,A client diagnosed with schizophrenia for the last 2 years tells the nurse who has
brought the morning medications, "That is not my pill! My pill is blue, not green." What
should the nurse tell the client?
You Selected:
"I will go back and check the drawer as well as telephone the pharmacy to check
about any possible changes in the medication color."
Correct response:
"I will go back and check the drawer as well as telephone the pharmacy to check
about any possible changes in the medication color."
Explanation:
It is important for the nurse to listen to the client and respect his or her knowledge about
the medication. In the other options, the nurse dismisses the client’s concern or gives a
possible explanation without checking out the specific situation. If the nurse has taken
the wrong medication, the client can prevent a medication error, and if there has been a
color change, the nurse can let the client know that information. In either case, helping a
psychotic client deal with reality appropriately is therapeutic.
Remediation:
Question 6 See full question
The nurse is admitting a child who has been diagnosed with bacterial meningitis to the
pediatric unit. The nurse should implement which type of isolation?
You Selected:
droplet precautions
Correct response:
droplet precautions
Explanation:
Bacterial meningitis is caused by one of three organisms, H. influenzae type
b, Neisseria meningitidis, or Streptococcus pneumoniae. All three organisms may be
transmitted through contact with respiratory droplets. These droplets are heavy and
typically fall within 3 feet (91.4 cm) of the client. Droplet precautions require, in addition
to standard (routine) precautions, that HCPs wear masks when coming into close
contact with the client. Standard or routine precautions, previously referred to as
universal precautions, are general measures used for all clients. Contact precautions
are used when direct or indirect contact with the client causes disease transmission.
Gowns and gloves are needed but not masks. Airborne precautions differ from droplet
in that the particles are smaller and may stay suspended in the air for longer periods of
, time. These clients require negative pressure rooms, and all heath care workers must
wear respirators.
Remediation:
Question 7 See full question
The nurse is preparing a community education program about preventing hepatitis B
infection. Which information should be incorporated into the teaching plan?
You Selected:
Good personal hygiene habits are most effective at preventing the spread of
hepatitis B.
Correct response:
The use of a condom is advised for sexual intercourse.
Explanation:
Hepatitis B is spread through exposure to blood or blood products and through high-risk
sexual activity. Hepatitis B is considered to be a sexually transmitted disease. High-risk
sexual activities include sex with multiple partners, unprotected sex with an infected
individual, male homosexual activity, and sexual activity with IV drug users. College
students are at high risk for development of hepatitis B and are encouraged to be
immunized. Alcohol intake by itself does not predispose an individual to hepatitis B, but
it can lead to high-risk behaviors such as unprotected sex. Good personal hygiene
alone will not prevent the transmission of hepatitis B.
Remediation:
Question 8 See full question
A client with a suspected brain tumor is scheduled for a computed tomography (CT)
scan. What should the nurse do when preparing the client for this test?
You Selected:
Determine whether the client is allergic to iodine, contrast dyes, or shellfish.
Correct response:
Determine whether the client is allergic to iodine, contrast dyes, or shellfish.
Explanation:
Because CT commonly involves use of a contrast agent, the nurse should determine
whether the client is allergic to iodine, contrast dyes, or shellfish. Neck immobilization is
necessary only if the client has a suspected spinal cord injury. Placing a cap over the
client's head may lead to misinterpretation of test results; instead, the hair should be
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