a charge nurse making rounds observes that an assistive personnel ap has applied wrist restraints to a client who is agitated and does not have a pres
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Nursing Elites

HESI LPN

HESI Leadership and Management Test Bank

1. A charge nurse making rounds observes that an assistive personnel (AP) has applied wrist restraints to a client who is agitated and does not have a prescription for restraints. Which of the following actions should the nurse take first?

Correct answer: A

Rationale: The correct action for the nurse to take first is to remove the restraints from the client's wrists. Restraints should not be applied without a prescription due to the risk of harm to the client. Removing the restraints promptly is a priority to ensure the client's safety. Reviewing nonrestraint alternatives, speaking with the AP, and informing the unit manager can follow after ensuring the client's immediate safety by removing the restraints.

2. A nurse is caring for a client who reports acute pain but refuses IM medication. The nurse distracts the client and quickly administers the injection. This illustrates which of the following?

Correct answer: C

Rationale: The correct answer is C, 'Battery.' Administering the injection without the client's consent constitutes battery. Assault involves the threat of harm, not the actual act. False imprisonment is restraining a client against their will, which does not apply here. Libel refers to a false written statement, which is not relevant in this scenario.

3. A nurse working in the emergency department is assessing several clients. Which of the following clients is the highest priority?

Correct answer: D

Rationale: The correct answer is D because shortness of breath with referred pain may indicate a serious condition, such as a cardiac event or pulmonary embolism, making this the highest priority. Option A, flank pain with diaphoresis, could suggest kidney-related issues but is not as immediately life-threatening as compromised breathing. Option B, active bleeding, though serious, can usually be controlled with proper interventions. Option C, a raised red skin rash, may indicate an allergic reaction but is not as urgent as respiratory distress with neck and shoulder pain.

4. Select the types of pain that are accurately coupled with an example of it. Select all that are correct.

Correct answer: D

Rationale: The correct answer is D because chronic pain is characterized by lasting for a prolonged period, typically more than 3-6 months, and is not necessarily related to acute injuries like a stab wound to the chest. Choices A, B, and C are incorrect because they do not accurately match the type of pain with its corresponding example. Radicular pain is pain that radiates along the nerve path, often from a pinched nerve or herniated disc, not a broken bone. Central neuropathic pain arises from damage to the central nervous system, such as after a stroke, not a leg injury. Peripheral neuropathic pain is caused by damage to the peripheral nerves, such as in diabetic neuropathy, not a fractured leg bone.

5. To resolve a conflict between staff members regarding potential changes in policy, a nurse manager decides to implement the changes she prefers regardless of the feelings of those who oppose those changes. Which of the following conflict-resolution strategies is the nurse manager using?

Correct answer: A

Rationale: The nurse manager is utilizing the competing conflict-resolution strategy. Competing involves making decisions based on one's preferences without considering the opinions or feelings of others. In this scenario, the nurse manager is unilaterally implementing changes despite opposition, demonstrating a competitive approach. Collaborating involves working together to find a mutually beneficial solution, compromising involves finding a middle ground acceptable to both parties, and cooperating involves working together towards a shared goal. These options are not applicable in this situation as the nurse manager is imposing her preferred changes without regard for others' input.

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