Nursing Elites

1. Who may legally give informed consent?

• A. an 86-year-old male with advanced Alzheimer's disease
• B. a 14-year-old girl needing an appendectomy who is not an emancipated minor
• C. a 14-year-old girl needing an appendectomy who is not an emancipated minor
• D. a 6-month-old baby needing bowel surgery

Correct answer: C

Rationale: The correct answer is a 14-year-old girl needing an appendectomy who is not an emancipated minor. Informed consent can be given by individuals who are competent and not minors. Minors are generally unable to provide informed consent unless they are emancipated. Choice A is incorrect because an 86-year-old male with advanced Alzheimer's disease is considered incompetent to make decisions. Choice D is incorrect because a 6-month-old baby is unable to provide consent. Emancipated minors are an exception to the minor rule, as they can provide consent for their own treatment.

2. In the context of milieu therapy, what is its primary purpose?

• A. exploring the client's perception of reality
• B. enhancing social interaction abilities
• C. addressing maladaptive behaviors
• D. providing routine daily experiences

Correct answer: D

Rationale: Milieu therapy aims to provide routine daily experiences to clients. By offering a structured and predictable environment, it helps individuals feel safe and secure, reducing disruptive behaviors. Exploring the client's perception of reality (choice A) may be part of therapy but not the primary focus. Enhancing social interaction abilities (choice B) and addressing maladaptive behaviors (choice C) are important aspects of therapy but not the primary purpose of milieu therapy.

3. There are many types of torts that can be committed against clients. They include all of the following except:

• A. assault.
• B. battery.
• C. negligence.
• D. felony.

Correct answer: D

Rationale: The correct answer is 'felony.' Felonies are serious crimes punishable by time in prison and are not considered types of torts. Types of torts include assault, battery, negligence, as well as other examples like slander, invasion of privacy, false imprisonment, and fraud. Assault involves the threat of harm, battery involves physical harm, and negligence involves a failure to exercise reasonable care. These are all civil wrongs (torts) rather than criminal offenses (felonies), making 'felony' the correct choice.

4. The nurse is assigning staff for the day. Which assignment should be given to the nursing assistant?

• A. Taking the vital signs of the 5-month-old with bronchiolitis
• B. Taking the vital signs of the 10-year-old with a 2-day postappendectomy
• C. Administering medication to the 2-year-old with periorbital cellulitis
• D. Adjusting the traction of the 1-year-old with a fractured tibia

Correct answer: B

Rationale: The most appropriate assignment for a nursing assistant is to take the vital signs of a stable patient. A 10-year-old with a 2-day postappendectomy is considered stable, and routine vital signs monitoring can be safely delegated to a nursing assistant. Clients with bronchiolitis, periorbital cellulitis, and a fractured tibia require more specialized care and assessment by a licensed nurse. Bronchiolitis involves an airway alteration, periorbital cellulitis indicates an infection, and a fractured tibia may raise concerns of abuse. Therefore, options A, C, and D are incorrect for delegation to a nursing assistant.

5. Ashley and her boyfriend Chris, both 19 years old, are transported to the Emergency Department after being involved in a motorcycle accident. Chris is badly hurt, but Ashley has no apparent injuries, though she appears confused and has trouble focusing on what is going on around her. She complains of dizziness and nausea. Her pulse is rapid, and she is hyperventilating. The nurse should assess Ashley's level of anxiety as:

• A. mild.
• B. moderate.
• C. severe.
• D. panic.

Correct answer: C

Rationale: Based on the symptoms described, Ashley's level of anxiety should be assessed as severe. In severe anxiety, individuals have difficulty solving problems and understanding their environment. They often exhibit somatic symptoms like dizziness, nausea, rapid pulse, and hyperventilation. In contrast, mild anxiety may lead to mild discomfort or even enhanced performance. Moderate anxiety involves grasping less information, mild difficulty in problem-solving, and slight changes in vital signs. Panic, on the other hand, is characterized by markedly disturbed behavior and a potential loss of touch with reality. Therefore, in Ashley's case, the presence of somatic symptoms and vital sign changes indicates severe anxiety.

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