Nursing Elites

1. A client is refusing to stay in the hospital because he does not agree with his healthcare treatment plan. The nurse stops the client from leaving due to concern for his health. Which of these legal charges could the nurse face?

• A. False imprisonment, as the nurse is not allowing the client to leave as he has decided to.
• B. Malpractice, as the nurse is intentionally keeping the patient from making his own decisions, thus violating that nursing duty.
• C. Invasion of privacy, as the nurse is getting involved in the patient's private decisions regarding healthcare.
• D. Negligence, as the nurse ignored the client's right to choose regarding his healthcare.

Correct answer: A

Rationale: Refusing to let a client leave against medical advice (AMA) is a form of false imprisonment. In this scenario, the nurse is restricting the client's freedom of movement by preventing him from leaving the hospital, even though he has expressed his wish to leave. False imprisonment is a legal charge the nurse could face in this situation. The other options are incorrect: - Malpractice refers to professional negligence or failure to provide adequate care, not allowing a patient to make their own decisions. - Invasion of privacy involves disclosing confidential information without consent, not preventing a patient from leaving. - Negligence is the failure to take reasonable care, but it does not specifically address the act of restricting a patient from leaving against their wishes.

2. What sign might the nurse observe in a client with a high ammonia level?

• A. coma
• B. edema
• C. hypoxia
• D. polyuria

Correct answer: A

Rationale: Coma is a sign that a nurse might observe in a client with a high ammonia level. Elevated ammonia levels can lead to hepatic encephalopathy, a condition characterized by impaired brain function, which can progress to coma. Edema (choice B) is swelling caused by excess fluid trapped in body tissues, not typically associated with high ammonia levels. Hypoxia (choice C) is a condition of inadequate oxygen supply to tissues and is not directly related to high ammonia levels. Polyuria (choice D) refers to excessive urination and is not a typical sign of high ammonia levels.

3. The nurse on the 3-11 shift is assessing the chart of a client with an abdominal aneurysm scheduled for surgery in the morning and finds that the consent form has been signed, but the client is unclear about the surgery and possible complications. Which is the most appropriate action?

• A. Call the surgeon and ask them to see the client to clarify the information
• B. Explain the procedure and complications to the client
• C. Check the physician's progress notes to see if understanding has been documented
• D. Check with the client's family to see if they understand the procedure fully

Correct answer: A

Rationale: The most appropriate action in this scenario is to call the surgeon and ask them to see the client to clarify the information. It is the responsibility of the physician to explain and clarify the procedure to the client, ensuring informed consent. Answer B is incorrect as nurses should not provide detailed medical explanations beyond their scope of practice. Answer C is incorrect as the physician's notes may not capture the client's current understanding accurately. Answer D is incorrect because the client's own understanding, not the family's, is crucial for informed decision-making regarding the surgery.

4. What instruction should a client who is about to undergo pelvic ultrasonography be given by a healthcare provider?

• A. "Urinate prior to the test."?
• B. "Have someone drive you home."?
• C. "Do not drink after midnight."?
• D. "Drink plenty of water."?

Correct answer: D

Rationale: The correct instruction for a client about to undergo pelvic ultrasonography is to 'Drink plenty of water.' A full bladder is required to serve as a landmark to define pelvic organs during the procedure. It is important to ensure the bladder is adequately filled. 'Urinate prior to the test' (Choice A) would not be appropriate as a full bladder is needed for better visualization. 'Have someone drive you home' (Choice B) is unnecessary as no sedation is given during the procedure, so the client can drive home on their own. 'Do not drink after midnight' (Choice C) is unrelated and not necessary for a pelvic ultrasonography examination.

5. A nurse provides instructions to a mother about crib safety for her infant. Which statement by the mother indicates a need for further instructions?

• A. ''Wood surfaces on the crib need to be free of splinters and cracks.''
• B. ''I need to keep large toys out of the crib.''
• C. ''The distance between the slats needs to be no more than 4 inches wide to prevent entrapment of my infant's head or body.''
• D. ''The drop side needs to be impossible for my infant to release.''

Correct answer: C

Rationale: The correct answer is, ''The distance between the slats needs to be no more than 4 inches wide to prevent entrapment of my infant's head or body.'' This statement indicates a need for further instructions as the distance between the slats should be no more than 2? inches to prevent entrapment of the infant's head and body, not 4 inches. Allowing a larger gap can pose a risk of entrapment or injury to the infant. Keeping large toys out of the crib is essential to prevent the infant from using them to climb out, which could result in serious injuries. Ensuring the drop side of the crib is impossible for the infant to release is crucial to prevent falls and injuries. Additionally, maintaining wood surfaces on the crib free of splinters, cracks, and lead-based paint is vital for the infant's safety and well-being.

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