NCLEX Practice Exam for Management of Care

EXPLANATION

 

✔Correct answer:

"It's understandable that he's acting out due to fear. Let's work together to devise a strategy." This response acknowledges the nursing assistant's feelings and provides a supportive and collaborative approach to address the challenging situation. By recognizing that the client's difficult behavior may stem from fear, Nurse Thomas demonstrates empathy and understanding, which are crucial in a therapeutic relationship. The suggestion to work together to devise a strategy fosters teamwork and ensures that the nursing assistant does not feel alone in managing the situation.

This approach also aligns with principles of therapeutic communication and problem-solving in nursing. It encourages reflection on the client's behavior, understanding underlying issues, and developing a plan that can improve care and reduce frustration for the caregiver.

Think of it like trying to solve a puzzle. When a piece doesn't fit, working together with someone can help find a new perspective or approach to complete the puzzle more effectively.

To effectively manage challenging client behaviors, nurses should:

• Encourage open communication among team members to share experiences and strategies.
• Identify potential underlying causes of the client’s behavior, such as fear, pain, or unmet needs.
• Develop a care plan that includes specific interventions to address the client's emotional and physical needs.
• Provide training and support to staff on how to handle difficult situations and manage stress.
• Offer opportunities for staff to debrief and discuss their feelings after challenging encounters.

 

✘Incorrect answer options:

"Focus on your other tasks for now. We'll arrange for someone else to attend to him tomorrow." This response does not address the underlying issue or provide support to the nursing assistant. It might also neglect the client's immediate needs and can lead to inconsistent care.

"I will have a conversation with him to understand the situation and determine the next steps." While this shows a proactive approach to addressing the client's behavior, it does not involve the nursing assistant in the problem-solving process, missing an opportunity for collaboration and support.

"He's dealing with numerous issues. It's important to remain patient and understanding." This response, though empathetic, does not offer a solution or acknowledge the nursing assistant's frustration. It may leave the assistant feeling unsupported and alone in handling the difficult situation.

 

References

• Arnold, E. C., & Boggs, K. U. (2019). Interpersonal Relationships: Professional Communication Skills for Nurses. Elsevier.
• American Nurses Association. (2015). Code of Ethics for Nurses with Interpretive Statements. Silver Spring, MD: Nursebooks.org.

EXPLANATION

 

✔Correct answer:

Refuse to show him the chart without the patient's consent. The correct action is to refuse to show the chart without the patient's consent. This approach complies with the Health Insurance Portability and Accountability Act (HIPAA) regulations, which protect patient privacy and confidentiality. Even though the father is a physician, he does not have the right to access the patient’s medical records without her explicit permission.

Ensuring the patient's consent is obtained before sharing any medical information respects her autonomy and confidentiality. This practice is crucial for maintaining trust in the healthcare system and ensuring compliance with legal and ethical standards.

Think of a medical chart like a locked diary. Just because someone is a teacher doesn’t mean they can read a student’s diary without permission. Similarly, being a physician does not give automatic access to a patient’s private medical information without consent.

The nurse should inform the father of the need for the patient’s consent and then proceed accordingly based on the patient’s wishes.

• Politely explain to the father that patient consent is required to access medical records.
• Communicate with the patient to obtain her permission if she agrees to share her medical information with her father.
• Document the patient’s consent and then allow access to the medical records as appropriate.
• If the patient does not consent, maintain confidentiality and inform the father of her decision.

 

✘Incorrect answer options:

Allow him to see the chart since he is a physician. This violates HIPAA regulations and the patient's right to privacy. Being a physician does not grant automatic access to medical records without the patient’s consent.

Ask him to sign a confidentiality agreement before viewing the chart. While confidentiality agreements are important, they do not replace the need for patient consent. The patient’s permission is still required before any information can be shared.

Provide a summary of the surgery without showing the chart. Sharing any information without the patient’s consent is still a violation of privacy regulations. The nurse must obtain explicit permission from the patient before disclosing any details about her medical care.

 

References

• American Nurses Association. (2015). Code of Ethics for Nurses with Interpretive Statements. Silver Spring, MD: Nursebooks.org.
• U.S. Department of Health and Human Services. (2013). Summary of the HIPAA Privacy Rule. Retrieved from https://www.hhs.gov/hipaa/for-professionals/privacy/laws-regulations/index.html

EXPLANATION

 

✔Correct answer:

Behaviors that are considered normal within the client's culture might be wrongly categorized as abnormal, unethical, or irrational. Understanding the cultural aspects of a client’s background is crucial because cultural norms and values significantly influence behavior, communication styles, health beliefs, and practices. Misinterpreting these behaviors can lead to incorrect assessments, biased judgments, and ineffective care.

Cultural competence in nursing involves recognizing and respecting diverse cultural perspectives and practices. By understanding a client’s cultural background, a nurse can provide more personalized and effective care, avoiding misunderstandings and fostering a respectful and therapeutic nurse-client relationship.

Imagine visiting a country where it's customary to greet people with a bow instead of a handshake. If you don’t understand this cultural norm, you might feel confused or think their behavior is strange. Similarly, nurses need to understand cultural norms to avoid misinterpreting patient behaviors.

Nurses should conduct culturally sensitive assessments and incorporate cultural knowledge into care plans. This includes asking open-ended questions about cultural practices, listening to the client’s perspectives, and being mindful of cultural influences on health behaviors.

• Ask the client about their cultural beliefs and practices related to health and wellness.
• Respect cultural differences in communication styles, such as eye contact, personal space, and gestures.
• Incorporate culturally appropriate interventions and education into the care plan.
• Advocate for the client’s cultural needs within the healthcare team to ensure comprehensive care.
• Continuously educate oneself on cultural competence to better understand and serve diverse populations.

 

✘Incorrect answer options:

The client's behavior should be interpreted based on common beliefs and stereotypes. Relying on stereotypes is inappropriate and can lead to biased and inaccurate assessments. Cultural competence involves understanding and respecting individual differences rather than making assumptions based on stereotypes.

The interaction between individuals from different cultures will be guided by their personal values. While personal values do play a role in interactions, this option does not address the importance of understanding cultural norms and practices to avoid misinterpretation of behaviors.

The nurse should base her understanding solely on her knowledge of various developmental mental stages. Developmental stages are important, but understanding cultural aspects provides a broader context for interpreting behaviors and practices, ensuring a holistic and accurate assessment.

 

References

• Giger, J. N., & Haddad, L. (2020). Transcultural Nursing: Assessment and Intervention. Elsevier.
• Andrews, M. M., & Boyle, J. S. (2019). Transcultural Concepts in Nursing Care. Lippincott Williams & Wilkins.

EXPLANATION

 

✔Correct answer:

Linsay is entitled to receive information about the medications prescribed to her. Patients have the right to be informed about the medications they are prescribed, including their purpose, benefits, potential side effects, and any alternatives. Educating Linsay about her medication helps her to understand the importance of adherence and empowers her to make informed decisions about her treatment. This approach promotes patient autonomy, builds trust, and can potentially improve medication compliance.

Educating patients about their medications is a fundamental aspect of nursing care. Providing clear and concise information about the purpose and side effects of medications can help mitigate fears and resistance, which is particularly important in managing chronic conditions like schizophrenia. Understanding side effects such as drowsiness can lead to discussions about managing these side effects or possibly adjusting the medication regimen in consultation with the healthcare provider.

Imagine you’re given a new tool to use at work but are not told how it functions or what issues to expect. You’d likely be hesitant to use it. However, if someone explains how it works and how to handle potential problems, you’d be more confident and effective in using it.

Providing patient education involves several key steps to ensure the information is understood and retained:

• Assess Linsay’s current knowledge about her medication and her readiness to learn.
• Provide information using simple, non-technical language, and confirm understanding through teach-back methods.
• Address any concerns Linsay has, such as the side effect of drowsiness, and discuss potential strategies to manage these side effects.
• Encourage Linsay to ask questions and express her concerns openly, ensuring a two-way communication channel.
• Document the education provided and Linsay’s response to the information.

 

✘Incorrect answer options:

The nurse should refer Linsay to the psychiatrist for detailed information about her medication. While psychiatrists play a crucial role in medication management, nurses are also responsible for patient education regarding medications. This ensures that Linsay receives timely information and support directly from the nurse.

Whether to educate Linsay about her medication is solely at the nurse's discretion. Patient education is a critical responsibility and is not solely at the nurse's discretion. It is an essential part of patient care and informed consent, ensuring patients understand their treatment plan.

Educating clients with schizophrenia about their medication side effects could lead to increased psychosocial complications. There is no evidence to suggest that educating patients with schizophrenia about their medications will lead to increased psychosocial complications. In fact, education often helps in reducing anxiety and improving adherence, as patients feel more in control and aware of their treatment.

 

References

• American Nurses Association. (2015). Code of Ethics for Nurses with Interpretive Statements. Silver Spring, MD: American Nurses Association.
• Townsend, M. C., & Morgan, K. I. (2017). Psychiatric Mental Health Nursing: Concepts of Care in Evidence-Based Practice. F.A. Davis Company.

EXPLANATION

 

✔Correct answer:

Clearly communicate the professional boundaries of the nurse-client relationship. This response is the most appropriate because it addresses the situation directly and professionally while maintaining the therapeutic relationship. By clearly communicating the boundaries, Nurse Brown can ensure that the client understands the nature of the nurse-client relationship, which is essential for maintaining professionalism and ensuring the focus remains on the client’s care.

Maintaining professional boundaries is a key aspect of nursing ethics and practice. It helps prevent conflicts of interest, maintains trust, and protects both the client and the nurse from potential harm or misunderstandings.

Think of it like a teacher-student relationship. While a teacher may be friendly and supportive, there are clear boundaries to ensure the relationship remains professional and focused on education.

To manage and reinforce professional boundaries, nurses should:

• Explain the importance of maintaining a professional relationship and how it benefits the client’s care.
• Set clear limits on personal interactions and avoid situations that could be misconstrued as personal or social.
• Document any instances of boundary-crossing behaviors and report them to a supervisor if necessary.
• Seek guidance from a supervisor or ethics committee if unsure about handling a particular situation.
• Provide support and resources for the client to understand the importance of professional boundaries.

 

✘Incorrect answer options:

Limit interactions with the client as much as possible. While this might seem like an immediate solution, it does not address the underlying issue or educate the client on professional boundaries. It might also negatively impact the client’s care.

Inform the client that hospital policies strictly forbid dating between clients and healthcare staff. This response, though factual, is not as effective in maintaining a therapeutic relationship. It focuses more on policy than on explaining the importance of professional boundaries in the nurse-client relationship.

Directly tell the client that such behavior is considered inappropriate. While setting boundaries is necessary, this approach might come across as punitive or confrontational, potentially damaging the therapeutic relationship. It’s better to explain the rationale behind maintaining professional boundaries in a more supportive manner.

 

References

• American Nurses Association. (2015). Code of Ethics for Nurses with Interpretive Statements. Silver Spring, MD: Nursebooks.org.
• Potter, P. A., Perry, A. G., Stockert, P. A., & Hall, A. M. (2020). Fundamentals of Nursing. Elsevier.

EXPLANATION

 

✔Correct answer:

Inform the physician, fill out an incident report, and document both the physician's notification and any patient assessments conducted.  When a medication error occurs, it is crucial to follow a structured and comprehensive process to ensure patient safety and proper documentation. This involves immediately informing the physician to determine the necessary medical interventions and patient monitoring. Filling out an incident report is essential for institutional accountability and to facilitate quality improvement processes. Documenting the physician's notification and patient assessments in the nursing notes ensures a clear, accurate record of the events and the care provided.

Imagine you're driving a car and accidentally bump into a parked car. The correct action is to inform the car owner (physician), document the incident with a note (incident report), and note the details of what happened and any damage in your logbook (nursing notes).

In the event of a medication error, the following steps should be taken:

• Immediately inform the physician to determine the appropriate course of action for the patient's safety.
• Conduct a thorough patient assessment to identify any adverse effects or reactions to the medication error.
• Complete an incident report detailing the medication error and any patient responses or actions taken.
• Document the incident in the patient's medical record, including the notification of the physician and the outcomes of patient assessments.
• Implement any corrective actions as advised by the physician to mitigate potential harm to the patient.

 

✘Incorrect answer options:

Inform the house supervisor, closely monitor the patient, and document the incident only if the patient shows adverse or unexpected reactions. While informing the house supervisor and monitoring the patient are important steps, this option is incomplete as it fails to address the necessity of notifying the physician immediately and documenting the error regardless of patient reaction.

Contact the physician and record in the nursing notes that the doctor has been informed of the medication error. This option correctly includes notifying the physician and documenting it in the nursing notes, but it neglects the important step of completing an incident report, which is vital for institutional learning and quality improvement.

Alert the supervisor, complete a medication error incident report, and note in the nursing records that an incident report has been filed. Notifying the supervisor and completing an incident report are important steps, but this option is incorrect because it omits the critical step of notifying the physician, who needs to assess and manage any potential impacts on the patient.

 

References

• Cherry, B., & Jacob, S. R. (2019). Contemporary Nursing: Issues, Trends, & Management. Elsevier.
• Hughes, R. G. (2008). Patient Safety and Quality: An Evidence-Based Handbook for Nurses. Agency for Healthcare Research and Quality (US).

EXPLANATION

 

✔Correct answer:

Consent forms are mandatory for all invasive procedures. The principle guiding Nurse Garcia's next step is that consent forms are mandatory for all invasive procedures. This requirement is both a legal and ethical obligation to ensure that the patient has been informed about the procedure, understands the risks and benefits, and has given voluntary consent.

Informed consent is a fundamental patient right and a legal requirement. It ensures that the patient is fully aware of what the surgery entails and consents to the procedure voluntarily. Administering pre-medication without obtaining this consent could have legal and ethical implications for both the nurse and the healthcare institution.

Imagine signing a contract before starting a job. You need to understand and agree to the terms before proceeding. Similarly, a patient must understand and agree to the surgery before it takes place.

Nurse Garcia should immediately halt further pre-operative preparations and inform the surgical team about the missing consent form. She must ensure that the patient signs the consent form before proceeding with the surgery.

• Stop any further pre-medication or surgical preparations until the consent form is signed.
• Explain the situation to the patient and ensure they understand the need to sign the consent form.
• Facilitate the signing of the consent form by the patient, ensuring that they have no lingering questions or concerns about the procedure.
• If the patient is unable to give consent due to the effects of pre-medication, inform the surgical team and follow hospital policy, which may involve rescheduling the surgery or seeking alternative methods to obtain valid consent.
• Document the incident and the steps taken to rectify the situation in the patient's medical record.

 

✘Incorrect answer options:

She should promptly get the consent form signed by the patient. While obtaining the patient’s consent is necessary, it is inappropriate to do so after administering pre-medication, as this may impair the patient's ability to provide informed consent. The patient must be fully alert and capable of understanding the information provided.

Implied consent is assumed when a patient is admitted for surgery, even if the surgery consent form is not signed. Implied consent does not apply to invasive procedures like surgery. Explicit, informed consent documented by a signed consent form is required by law.

She should seek a signature from the next of kin for the necessary consent form. Consent should be obtained directly from the patient whenever possible. Next of kin can only provide consent if the patient is legally incapacitated or unable to give consent, and appropriate legal documentation must be in place to verify this authority.

 

References

• Guido, G. W. (2020). Legal and Ethical Issues in Nursing (7th ed.). Pearson.
• Pozgar, G. D. (2019). Legal and Ethical Essentials of Health Care Administration (4th ed.). Jones & Bartlett Learning.

EXPLANATION

 

✔Correct answer:

Notify the nursing supervisor about her concerns regarding Angelina. The most appropriate first step for Maegan to take is to notify the nursing supervisor about her concerns regarding Angelina. This approach aligns with professional standards and ensures patient safety. Intoxication in a healthcare setting is a serious issue that can impair a nurse's ability to perform their duties, potentially endangering patients. By reporting her observations to the supervisor, Maegan is taking a responsible action that allows for a proper and objective assessment of the situation and ensures that appropriate measures are taken.

Reporting to a supervisor ensures that the situation is handled confidentially and professionally, following hospital policies and procedures. The supervisor is responsible for investigating the issue and determining the appropriate actions, which may include a drug test, counseling, or other interventions to address the problem.

Imagine you notice a bus driver who seems unsteady and smells of alcohol. Instead of confronting the driver directly or ignoring the situation, the safest and most responsible action would be to notify the bus company so they can ensure the driver is not putting passengers at risk.

Nurses play a critical role in maintaining a safe and professional healthcare environment. In situations where a colleague's behavior raises concerns about potential intoxication, it is essential to take appropriate actions to protect patient safety and uphold professional standards. The following interventions are recommended:

• Document the observations objectively, noting specific behaviors and physical signs without making assumptions.
• Maintain confidentiality and avoid discussing the situation with other colleagues to prevent gossip and preserve professional integrity.
• Support a work environment that prioritizes patient safety and professional conduct.

 

✘Incorrect answer options:

Offer Angelina advice on substance abuse without taking further action. Offering advice without taking further action does not address the immediate safety concerns and lacks the necessary formal intervention to ensure patient safety and professional accountability.

Directly accuse Angelina of intoxication and insist she stops working immediately. Directly accusing Angelina could lead to conflict and does not follow appropriate procedural steps. It's important to handle such situations professionally through the correct channels.

Disregard the observations and continue with her own duties. Ignoring the observations could put patients at risk and does not align with the ethical and professional responsibilities of a nurse to ensure a safe care environment.

 

References

• American Nurses Association. (2015). Code of Ethics for Nurses with Interpretive Statements. Silver Spring, MD: American Nurses Association.
• Cherry, B., & Jacob, S. R. (2016). Contemporary Nursing: Issues, Trends, & Management. Elsevier Health Sciences.

EXPLANATION

 

✔Correct answer:

Provide care for the nostrils and mouth. Unlicensed assistive personnel (UAP) are trained to perform basic care tasks that do not require specialized nursing judgment or skills. Providing care for the nostrils and mouth falls within the scope of their training and competencies. This task involves ensuring that Melissa's nostrils are clean and free from irritation and that her mouth is kept moist and clean, which are essential aspects of patient comfort and hygiene but do not require clinical assessment or decision-making.

Delegating tasks appropriately is crucial for effective patient care. According to the principles of delegation, tasks assigned to UAP should be within their training and competencies and should not involve assessment, clinical judgment, or decision-making. Providing mouth and nostril care is a routine, non-invasive task that can be safely performed by UAP, allowing the nurse to focus on more complex aspects of Melissa's care.

Imagine a construction site where a supervisor (the nurse) delegates sweeping and cleaning tasks to a laborer (UAP). The laborer can efficiently handle these tasks, freeing the supervisor to oversee more complex construction processes that require expertise and experience.

Ensuring proper delegation in a healthcare setting is key to maintaining patient safety and efficient workflow. Here are essential considerations for delegation:

• Ensure that the task is within the UAP's job description and competencies.
• Provide clear instructions and ensure the UAP understands the importance of the task.
• Supervise and offer support as needed to ensure the task is performed correctly.
• Evaluate the outcome of the task to ensure it meets the necessary standards of care.

 

✘Incorrect answer options:

Irrigate the nasogastric tube using the prescribed solution. Irrigating a nasogastric tube requires clinical knowledge and skill to ensure that the procedure is performed correctly and safely. This task should be performed by a licensed nurse who can assess the patient's response and manage any complications that may arise.

Observe Melissa for signs of nausea or any other complications. Observing for complications involves clinical assessment and judgment, which are beyond the scope of practice for UAP. The nurse should perform this task to ensure that any signs of complications are promptly recognized and addressed.

Monitor and document the type and volume of nasogastric tube drainage. Monitoring and documenting nasogastric tube drainage involves assessment and documentation of clinical data, which require nursing judgment and expertise. This task should be performed by a licensed nurse to ensure accurate and appropriate management of the patient's condition.

 

References

• American Nurses Association. (2012). Delegation and Nursing Judgment. Silver Spring, MD: American Nurses Association.
• Yoder-Wise, P. S. (2019). Leading and Managing in Nursing. Elsevier Health Sciences.

EXPLANATION

 

✔Correct answer:

"I'm sorry, but I can't promise to keep information confidential." This response is the most appropriate because it sets clear boundaries and maintains the nurse's ethical and legal responsibilities. Nurses have a duty to report certain information, especially if it pertains to the client's safety or the safety of others. This includes information related to self-harm, harm to others, or any illegal activities. By stating that she cannot promise confidentiality, Nurse Johnson is being honest with the client and ensuring that the client understands the limits of confidentiality.

Healthcare professionals are bound by laws and ethical codes that require them to disclose certain information to protect the client and others. For example, mandatory reporting laws require healthcare providers to report suspicions of abuse, neglect, or threats of harm. This helps to ensure that appropriate actions can be taken to protect individuals from harm.

Imagine you're a teacher, and a student wants to tell you something but asks you to promise not to tell anyone. You know that if the student mentions anything about being hurt or in danger, you must report it to ensure their safety. Similarly, a nurse must be transparent about their obligation to report certain information to maintain the client's safety and wellbeing.

When handling situations where a client wants to share information confidentially, it's important for nurses to:

• Communicate the limits of confidentiality clearly and compassionately.
• Encourage the client to share the information while explaining the reasons for these limits.
• Reassure the client that their information will be handled with care and shared only with those who need to know for their safety and treatment.
• Document the interaction accurately and follow up with appropriate actions as required by the situation and institutional policies.

 

✘Incorrect answer options:

"It may depend on what you're going to tell me." This response is ambiguous and does not provide the client with clear information about the limits of confidentiality. It can lead to misunderstandings and potentially result in the client feeling betrayed if the nurse needs to disclose the information later.

"I'm required to document and share significant information with the relevant team." While accurate, this response can come across as impersonal and may discourage the client from sharing important information. It lacks the empathetic communication needed to build trust.

"I need to inform the entire treatment team about everything you tell me." This response is too broad and may unnecessarily alarm the client. Not all information needs to be shared with the entire treatment team, only that which is relevant to the client's care and safety.

 

References

• American Nurses Association. (2015). Code of Ethics for Nurses with Interpretive Statements. Silver Spring, MD: American Nurses Association.
• Butts, J. B., & Rich, K. L. (2019). Nursing Ethics: Across the Curriculum and Into Practice. Jones & Bartlett Learning.

EXPLANATION

 

✔Correct answer:

Oversee a nursing assistant who will be responsible for skin care. In this scenario, overseeing a nursing assistant (NA) who is responsible for the client's skin care is a practical and efficient approach. The nursing assistant can handle routine skin care tasks, which helps ensure that the client receives regular attention to prevent complications such as pressure ulcers and infections. The RN should still manage and supervise the overall care plan, ensuring that the NA follows proper protocols and reports any changes in the client's condition promptly.

Regular skin care is crucial for a client on bed rest with a skin tear and hematoma. The nursing assistant can perform routine tasks such as repositioning the client, keeping the skin clean and dry, and applying prescribed topical treatments. This approach allows the RN to focus on more complex assessments and interventions while ensuring that essential skin care tasks are consistently performed.

Think of the RN as the chef in a restaurant who designs the menu and oversees the kitchen, while the nursing assistant is like the sous-chef who handles specific tasks such as chopping vegetables and preparing ingredients. Both roles are essential for delivering a well-prepared meal (or, in this case, comprehensive patient care).

The RN should provide clear instructions and training to the nursing assistant on proper skin care techniques and ensure regular communication to monitor the client's condition.

• Instruct the nursing assistant on the importance of regular repositioning to prevent pressure ulcers.
• Train the nursing assistant on how to perform proper skin cleansing and application of prescribed treatments.
• Establish a routine schedule for skin assessments and care tasks.
• Ensure the nursing assistant understands the signs of infection or worsening condition and the protocol for reporting these to the RN.
• Regularly review the client’s care plan and make adjustments as needed based on the nursing assistant's observations and reports.

 

✘Incorrect answer options:

Allocate an RN to manage all aspects of the client's care. While having an RN manage all aspects of care ensures a high level of expertise, it is not always the most efficient use of resources, especially when routine tasks can be effectively handled by a nursing assistant under RN supervision.

Entrust the entire care of the client to an unlicensed assistive personnel. Unlicensed assistive personnel (UAP) do not have the necessary training to manage all aspects of care, particularly for clients with complex needs like a skin tear and hematoma. This could result in inadequate care and increased risk of complications.

Delegate a nursing assistant to assist the client with activities of daily living. While this is important, it does not encompass the necessary skin care required for a client with a skin tear and hematoma. The focus should be on both ADLs and specialized skin care.

 

References

• Berman, A., Snyder, S. J., & Frandsen, G. (2016). Kozier & Erb's Fundamentals of Nursing: Concepts, Process, and Practice. Pearson.
• Potter, P. A., Perry, A. G., Stockert, P. A., & Hall, A. M. (2016). Fundamentals of Nursing. Elsevier Health Sciences.

EXPLANATION

 

✔Correct answer:

Clarify the professional boundaries inherent in a therapeutic nurse-client relationship. The nurse should address Denver's behavior by clearly explaining the professional boundaries that exist within a therapeutic nurse-client relationship. This response helps to maintain a safe and appropriate environment for both the client and the nurse. It is important to remind Denver that the focus of their interactions is on his care and treatment, and that personal relationships outside of this professional context are not permissible.

In psychiatric and other healthcare settings, maintaining clear professional boundaries is crucial to protect the integrity of the therapeutic relationship and ensure effective care. Nurses must communicate these boundaries respectfully and assertively to prevent any potential for misunderstandings or inappropriate behavior.

Imagine a personal trainer whose client repeatedly asks them to hang out socially outside of the gym. The trainer would need to explain that their relationship is strictly professional and focused on the client's fitness goals. Similarly, the nurse must clarify the professional boundaries to ensure the therapeutic nurse-client relationship remains appropriate and focused on the client's health and well-being.

When addressing boundary issues with clients, nurses should:

• Communicate clearly and respectfully about the nature of the nurse-client relationship.
• Reinforce the importance of maintaining a professional focus on the client’s treatment and well-being.
• Document the interaction and any boundary-setting discussions to ensure proper records.
• Seek support or guidance from supervisors or colleagues if needed to handle the situation effectively.

 

✘Incorrect answer options:

Explain to Denver that hospital policies strictly forbid staff from dating clients. While this is true, focusing solely on policy may come across as impersonal and does not address the underlying need to establish and maintain professional boundaries.

Request to be reassigned to a different client or to work in another unit. This option avoids addressing the issue directly and does not help Denver understand the importance of professional boundaries. It also does not provide an opportunity to reinforce appropriate behavior.

Inform Denver that this type of behavior is considered inappropriate. Labeling the behavior as inappropriate without further explanation may be perceived as punitive and does not help educate the client about the reasons behind maintaining professional boundaries.

 

References

• American Nurses Association. (2015). Code of Ethics for Nurses with Interpretive Statements. Silver Spring, MD: American Nurses Association.
• Townsend, M. C., & Morgan, K. I. (2017). Psychiatric Mental Health Nursing: Concepts of Care in Evidence-Based Practice. F.A. Davis Company.

EXPLANATION

 

✔Correct answer:

Designate one nurse to routinely visit and attend to the client. Assigning a specific nurse to routinely visit and attend to the client is the most effective approach to manage the situation. This strategy ensures continuity of care and helps build a trusting relationship between the client and the nurse. It allows for consistent assessment and addressing of the client’s needs, which can reduce anxiety and the frequent calling out behavior. This approach also helps in efficiently managing the workload among the nursing staff.

Having a designated nurse can provide the client with a sense of security and stability. It reduces the anxiety that can come from seeing different faces and not knowing who will respond to their needs. The consistency in care helps in building trust and rapport, which is crucial for the psychological well-being of the patient.

Imagine you are in a new school and feel anxious about who to ask for help. If a specific teacher checks in on you regularly, you'll feel more secure knowing who to turn to, rather than constantly seeking help from different people.

The designated nurse should conduct regular assessments to understand the underlying reasons for the client's behavior. This might include evaluating for pain, anxiety, loneliness, or other unmet needs. The nurse should also communicate effectively with the client, offering reassurance and clearly explaining when they will return.

• Establish a routine visit schedule and inform the client about it.
• Document the client’s needs and any interventions provided.
• Communicate the plan with other staff members to ensure continuity during shift changes.
• Provide emotional support and active listening to understand and address the client’s concerns.

 

✘Incorrect answer options:

Organize a schedule for every staff member to check on the client's needs hourly. While this approach ensures frequent checks, it lacks continuity and consistency, which are crucial for building a trusting relationship and reducing anxiety.

Comfort the client by promising that one staff member will regularly check in to address any needs. Promising regular checks by one staff member may provide some reassurance, but it lacks the specificity and structure that a designated nurse provides.

Slightly open the client's room door to reduce the distractions. This might reduce some distractions, but it does not address the root cause of the client's behavior and does not provide the needed reassurance and consistent care.

 

References

• Harkreader, H., Hogan, M. A., & Thobaben, M. (2007). Fundamentals of Nursing: Caring and Clinical Judgment. Saunders Elsevier.
• Potter, P. A., Perry, A. G., Stockert, P. A., & Hall, A. M. (2016). Fundamentals of Nursing. Elsevier Health Sciences.

EXPLANATION

 

✔Correct answer:

Ask the client for more specific information regarding their allegation of abuse. The nurse’s initial and most appropriate action is to ask the client for more specific information regarding their allegation of abuse. This step is crucial to gather essential details about the nature, timing, and context of the alleged abuse. By obtaining more information, the nurse can better understand the situation, assess the immediate risk to the client, and ensure appropriate actions are taken to protect the client and investigate the claim.

It's important to approach the client with empathy and without judgment. Clarifying the situation helps the nurse to determine the urgency and severity of the allegation. It also ensures that any immediate safety concerns are addressed promptly.

Imagine a friend tells you they're being bullied but doesn't give any specifics. Before taking any action or informing others, you would first ask who is bullying them, what exactly happened, and when it occurred. This way, you can provide the right support and ensure the appropriate steps are taken to address the issue effectively. Similarly, in the nursing scenario, the nurse needs to gather detailed information about the client's allegation of abuse to understand the situation fully and take the appropriate actions to ensure the client's safety and proper investigation.

Handling allegations of abuse requires a sensitive and structured approach to ensure the client's safety and to adhere to legal and ethical standards. The steps include:

• Listen to the client's complaint without making assumptions or judgments.
• Ask open-ended questions to gather detailed information about the alleged abuse (e.g., what happened, when it happened, and who was involved).
• Ensure the client's immediate safety and provide reassurance that their concerns are taken seriously.
• Document the client's statements accurately and report the allegation to the appropriate authorities and supervisors according to institutional policies.
• Follow up with the client to provide support and ensure that appropriate protective measures are in place.

 

✘Incorrect answer options:

Make a note of the client's statement in their chart and report the situation to the unit manager. While documenting the client's statement and reporting it to the unit manager are important steps, they should not be the initial response. Gathering more specific information first ensures that the nurse fully understands the situation and can provide a more accurate report.

Concentrate on confirming the client's orientation to time, place, and person. Assessing orientation may be necessary if there are concerns about the client's mental status, but it should not be the initial response. The priority is to address the client's urgent allegation of abuse and ensure their safety.

Facilitate the process of reporting the client's complaint to the police. Reporting to the police may be necessary depending on the details of the abuse allegation. However, the initial step should be to gather more specific information from the client to understand the nature and urgency of the situation before contacting law enforcement.

 

References

• American Nurses Association. (2015). Code of Ethics for Nurses with Interpretive Statements. Silver Spring, MD: American Nurses Association.
• Butts, J. B., & Rich, K. L. (2019). Nursing Ethics: Across the Curriculum and Into Practice. Jones & Bartlett Learning.

EXPLANATION

 

✔Correct answer:

Checking the name on the client's identification bracelet. The most reliable method for verifying a patient's identity before administering medication is to check the identification bracelet. This bracelet typically includes the patient’s name, date of birth, and a unique identification number, which are all essential for ensuring accurate identification. This method aligns with the "five rights" of medication administration (right patient, right drug, right dose, right route, and right time) and helps to prevent medication errors.

In clinical practice, using the identification bracelet is a standard procedure recommended by many healthcare organizations, including the Joint Commission, which emphasizes the importance of using at least two patient identifiers before administering medications or performing any medical procedures.

Think of the identification bracelet like a boarding pass for a flight. Just as the boarding pass ensures that a traveler boards the correct flight, the identification bracelet ensures that the nurse administers the correct medication to the right patient.

To ensure patient safety and prevent medication errors, nurses should always:

• Check the patient’s identification bracelet against the medication administration record (MAR).
• Use two identifiers, such as the patient’s name and date of birth, to confirm identity.
• Ask the patient to state their name and date of birth, if they are able, and verify this information against the bracelet and MAR.
• Ensure the information matches before proceeding with medication administration.
• Document the administration accurately in the patient's medical record.

 

✘Incorrect answer options:

Reviewing the medical record of the client. While reviewing the medical record is important for understanding the patient's medical history and current treatment plan, it does not directly verify the patient’s identity at the time of medication administration.

Confirming the client's name with the roommate. Relying on another patient to confirm identity is not a reliable method and can lead to errors. Roommates may not have the correct information or might confuse the identities, especially in settings with many residents.

Verifying the client's identity by asking if she is Mrs. Jefferson. This approach is problematic as it can lead to confirmation bias; the patient might mistakenly agree, especially if they have cognitive impairment or are not paying close attention. It is essential to ask open-ended questions like, "Can you tell me your name and date of birth?"

 

References

• Joint Commission. (2021). National Patient Safety Goals. Hospital Accreditation Program. https://www.jointcommission.org/standards/national-patient-safety-goals/
• Potter, P. A., Perry, A. G., Stockert, P. A., & Hall, A. M. (2020). Fundamentals of Nursing. Elsevier.

EXPLANATION

 

✔Correct answer:

A client who has had a myocardial infarction but is currently stable, free from pain, and not exhibiting dysrhythmias. Given Ms. Williams' background in the maternity unit, her critical care skills may not be as advanced as those regularly assigned to the critical care unit. Therefore, it is crucial to assign her a client whose condition is stable and requires less complex monitoring and interventions. The client who has had a myocardial infarction but is currently stable, free from pain, and not exhibiting dysrhythmias is the most suitable choice. This client requires standard monitoring and care, which aligns more closely with Ms. Williams' skills and experience.

When temporarily assigning nurses to different units, it is important to consider the complexity of the patient's condition and the nurse's experience and training. This ensures that patients receive safe and competent care, and that nurses are not placed in situations beyond their expertise.

Imagine a chef who specializes in baking is asked to work in a restaurant kitchen where complex cooking techniques are required. It would be safest to assign them to simpler tasks they can manage effectively, rather than complex ones that require specialized skills.

When assigning a nurse to a different unit, it is essential to:

• Evaluate the nurse's competencies and experience relevant to the new unit's requirements.
• Select clients with stable conditions and less intensive monitoring needs.
• Provide orientation and support to the nurse in the new unit to ensure a smooth transition.
• Ensure that there are experienced nurses available to assist with any unfamiliar situations or emergencies.

 

✘Incorrect answer options:

A client on a dopamine drip IV with the need for vital signs to be monitored every 5 minutes. This client requires continuous and intensive monitoring, as well as experience in managing dopamine drips and interpreting hemodynamic changes, which may be beyond Ms. Williams' experience in maternity care.

A client who had a pacemaker inserted this morning and is experiencing intermittent capture. This client is unstable and requires specialized cardiac knowledge and skills to manage the pacemaker and monitor for complications, which may not align with Ms. Williams' background.

A client with a tracheotomy that's 24 hours old and is showing signs of respiratory distress. Managing a new tracheotomy with signs of respiratory distress requires advanced airway management skills and close monitoring, which may be outside Ms. Williams' expertise from the maternity unit.

 

References

• American Nurses Association. (2015). Code of Ethics for Nurses with Interpretive Statements. Silver Spring, MD: American Nurses Association.
• Cherry, B., & Jacob, S. R. (2016). Contemporary Nursing: Issues, Trends, & Management. Elsevier Health Sciences.

EXPLANATION

 

✔Correct answer:

Adjust the visiting regulations for the family due to the prolonged nature of the client's recovery and the importance of familial support. Guillain-Barré syndrome is a severe condition that can result in prolonged hospitalization and significant physical and emotional stress for the patient. Familial support plays a critical role in the patient’s emotional well-being and recovery process. Given the severity of the patient's condition and the family's limited ability to visit during regular hours due to their work commitments, it is appropriate and compassionate to adjust the visiting regulations to accommodate their needs. This approach not only supports the patient’s emotional health but also respects the family’s circumstances.

Consider a student who can only study effectively at night due to daytime commitments. Allowing them to study at night when they are available would better support their learning and success, similar to how adjusting visiting hours supports the patient’s recovery and family connection.

In this scenario, Nurse Anderson should:

• Discuss the situation with hospital administration to obtain approval for adjusted visiting hours for the family.
• Ensure that the family's visits do not interfere with necessary medical care and the patient's need for rest.
• Coordinate with other healthcare team members to facilitate a supportive and flexible visiting schedule.
• Provide education to the family about the patient’s condition and the importance of their involvement in the recovery process.
• Document any changes to the visiting schedule and the reasons for these adjustments in the patient's medical record.

 

✘Incorrect answer options:

Inform the family that maintaining consistency in enforcing hospital rules is crucial to avoid grievances from other clients' families. This option does not consider the unique needs of the patient and family in this situation. Strictly adhering to the rules without considering individual circumstances may negatively impact the patient's emotional well-being and recovery.

Recommend that the family members visit in shifts during the established visiting hours, as the client requires rest at night. While this option attempts to find a compromise, it may not be feasible for the family due to their work commitments. It also overlooks the potential benefit of familial support for the patient’s recovery, even outside regular visiting hours.

Coordinate for a volunteer to accompany the client during daytime hours to meet socialization needs and assist with communication with the medical team. While having a volunteer can provide some social interaction, it does not replace the emotional and psychological support that family members can offer. This option does not address the family's need to be involved in the patient’s care and support.

 

References

• Smeltzer, S. C., Bare, B. G., Hinkle, J. L., & Cheever, K. H. (2010). Brunner & Suddarth's Textbook of Medical-Surgical Nursing. Lippincott Williams & Wilkins.
• Ignatavicius, D. D., Workman, M. L., Rebar, C. R., & Heimgartner, N. M. (2018). Medical-Surgical Nursing: Concepts for Interprofessional Collaborative Care. Elsevier.

EXPLANATION

 

✔Correct answer:

Ambulating a stable patient in the hallway. Ambulating a stable patient is a task that is typically within the scope of practice for a nursing assistant. This task does not require advanced nursing skills or assessments and is a common activity that nursing assistants are trained to perform. Ensuring the patient is stable and safe to ambulate is crucial, but once that is confirmed, this is an appropriate task for delegation.

Ambulating patients helps prevent complications such as deep vein thrombosis and promotes overall well-being, making it an important part of patient care that nursing assistants can effectively manage under the supervision of a registered nurse.

Delegating the task of ambulating a stable patient to a nursing assistant is like asking a lifeguard to monitor swimmers in a shallow pool. The lifeguard has the necessary skills to ensure safety, and the task is within their capability.

When delegating tasks to nursing assistants, nurses should:

• Ensure the nursing assistant has received proper training and is competent to perform the task.
• Clearly communicate any specific instructions or considerations related to the task.
• Verify that the patient is stable and does not have any contraindications for ambulation.
• Monitor the nursing assistant's performance periodically and be available to provide support if needed.
• Provide feedback and further training opportunities based on the nursing assistant's performance.

 

✘Incorrect answer options:

Administering a subcutaneous insulin injection. This task requires specific knowledge and skill to ensure proper technique and to monitor for adverse reactions. It is generally outside the scope of practice for nursing assistants, as it involves medication administration and assessment skills that require the expertise of a licensed nurse.

Performing a sterile dressing change. This task requires knowledge of sterile technique and wound care, which are typically beyond the training and scope of practice for nursing assistants. Performing sterile procedures carries a higher risk of infection if not done correctly, so it is best performed by a licensed nurse.

Developing a care plan for a new patient. Creating a care plan involves comprehensive assessment, critical thinking, and clinical judgment, which are responsibilities of a registered nurse. This task cannot be delegated to a nursing assistant, as it requires professional nursing knowledge and skills to ensure that the care plan meets the patient's needs.

 

References

• American Nurses Association. (2012). Principles for Delegation by Registered Nurses to Unlicensed Assistive Personnel (UAP). https://www.nursingworld.org/practice-policy/nursing-excellence/official-position-statements/id/principles-for-delegation-by-registered-nurses-to-unlicensed-assistive-personnel-uap/
• Potter, P. A., Perry, A. G., Stockert, P. A., & Hall, A. M. (2020). Fundamentals of Nursing. Elsevier.

EXPLANATION

 

✔Correct answer:

Realize that delivering holistic care involves respecting and incorporating the client's belief system into the care plan. Holistic care in nursing emphasizes the importance of considering the entire person, including their physical, emotional, social, and spiritual needs. For many patients, spiritual beliefs and practices, including those involving traditional healers or medicine men, play a crucial role in their overall well-being and recovery process. By respecting and incorporating the client's belief system into the care plan, Nurse Parker acknowledges the client's cultural and spiritual needs, which can enhance the healing process and patient satisfaction.

Holistic care is based on the recognition that health and healing are influenced by a combination of biological, psychological, social, and spiritual factors. When patients feel that their cultural and spiritual beliefs are respected, it can lead to improved trust and communication between the patient and healthcare provider, which is essential for effective care.

Imagine treating a plant that needs not only water (medical care) but also sunlight (spiritual support) to thrive. Ignoring the need for sunlight might result in a less healthy plant. Similarly, ignoring a patient's spiritual needs can impede their overall recovery.

Nurses should facilitate the inclusion of the patient's spiritual and cultural practices in the care plan while ensuring it does not interfere with medical treatment and hospital policies. This involves:

• Communicating with hospital administration to make exceptions for spiritual healers if necessary.
• Ensuring that any spiritual practices do not pose a risk to the patient or interfere with medical procedures.
• Collaborating with the healthcare team to create a care plan that incorporates the patient's spiritual needs.
• Providing a private and comfortable environment for the patient to receive visits from their spiritual healer.
• Educating the patient and family about any potential limitations or guidelines to ensure safety and compliance with hospital policies.

 

✘Incorrect answer options:

Recognize that the principle of justice requires equal treatment, disallowing privileges for one client that are not available to others. While the principle of justice is important, it must be balanced with the need for individualized, patient-centered care. Disallowing a visit from a medicine man without considering the patient's spiritual needs may not be in the best interest of holistic care.

Understand that faith healers do not qualify for the clergy exemption in the visitation guidelines. This answer overlooks the importance of cultural competence and individualized patient care. Many hospitals recognize the need to accommodate various spiritual and cultural practices, even if they are not part of the formal clergy.

Acknowledge that medicine men are not recognized by the hospital as legitimate healthcare providers. This statement fails to recognize the value of culturally competent care. While medicine men may not be recognized as healthcare providers, their role in the patient's spiritual and emotional well-being is significant and should be considered in the care plan.

 

References

• Dossey, B. M., Keegan, L., & Barrere, C. C. (2016). Holistic Nursing: A Handbook for Practice. Jones & Bartlett Learning.
• Berman, A., Snyder, S., & Frandsen, G. (2016). Kozier & Erb's Fundamentals of Nursing: Concepts, Process, and Practice. Pearson Education.

EXPLANATION

 

✔Correct answer:

"Before I can share any information, I need to have the client's written consent." The correct response is to request the client's written consent before sharing any personal health information. This ensures compliance with the Health Insurance Portability and Accountability Act (HIPAA) and other privacy laws that protect patient confidentiality. Without written consent, it is not appropriate to disclose any information about Mr. Clarkson's mental status or adjustment, even to another healthcare professional.

Protecting patient confidentiality is a fundamental ethical and legal obligation in healthcare. Sharing information without proper consent can lead to breaches of confidentiality and legal consequences. By obtaining written consent, the nurse ensures that Mr. Clarkson is aware of and agrees to the sharing of his personal health information.

Imagine you have personal information stored with a bank. If someone calls the bank asking for your details, the bank must first obtain your permission before sharing any information to ensure your privacy is protected.

Ensuring proper procedures are followed for sharing patient information includes:

• Verify the requestor's identity and relationship to the patient, ensuring they have a legitimate reason for accessing the information.
• Obtain written consent from the patient, specifying what information can be shared and with whom.
• Document the consent process, including the patient’s agreement and any information shared.
• Follow institutional policies and guidelines regarding patient information and privacy.

 

✘Incorrect answer options:

"As this is part of a referral process, I am permitted to share this information with you." Sharing information as part of a referral process without the patient's written consent still violates confidentiality laws. Proper consent must always be obtained.

"It's against policy to disclose any information over the phone, as your identity cannot be verified." While verifying identity is important, the primary issue is the need for the patient's written consent to share information. Policies typically address this requirement, and it would be inappropriate to share information regardless of the requestor's identity verification without consent.

"I apologize, but referral information can only be released by the client's primary healthcare providers." This statement is incorrect because it implies that only certain healthcare providers can share information, whereas the main concern is obtaining the patient's consent before any healthcare provider shares personal health information.

 

References

• American Nurses Association. (2015). Code of Ethics for Nurses with Interpretive Statements. Silver Spring, MD: American Nurses Association.
• Pozgar, G. D. (2020). Legal and Ethical Issues for Health Professionals. Jones & Bartlett Learning.