A client with human immunodeficiency virus (HIV) and acquired immunodeficiency syndrome confide that he is homosexual and his employer does not know his HIV status. Which response by the nurse is best?
A. “Would you like me to help you tell them?”
B. “The information you confide in me is confidential.”
C. “I must share this information with your family.”
D. “I must share this information with your employer.”
Answer Key
Pets are discouraged when parents are trying to allergy-proof a home for a child with bronchial asthma unless the pets are kept outside. Pets with hair or feathers are especially likely to trigger asthma attacks. A fish is a satisfactory pet for this child, but the parents should be taught to keep the fish tank clean to prevent it from harboring mold.
The mother of a child with bronchial asthma tells the nurse that the child wants a pet. Which of the following pets is most appropriate?
A. Cat.
B. Fish.
C. Gerbil.
D. Canary.
Answer Key
Pets are discouraged when parents are trying to allergy-proof a home for a child with bronchial asthma unless the pets are kept outside. Pets with hair or feathers are especially likely to trigger asthma attacks. A fish is a satisfactory pet for this child, but the parents should be taught to keep the fish tank clean to prevent it from harboring mold.
An elderly client is being admitted to same-day surgery for cataract extraction. The client has several diamond rings. The nurse should explain to the client that:
A. Her rings will be taped before the surgery.
B. She will sign a valuables envelope that will be placed in a safe.
C. The rings will be locked in the narcotics box.
D. The nursing supervisor will hold onto the rings during the surgery.
Answer Key
Under the policy for valuables, the nurse documents the description on an envelope with the client, the client, and the nurse sign the envelope, and the valuables envelope is locked in the safe. The other options increase the risk of loss or damage to the client’s valuables.
When an infant resumes taking oral feedings after surgery to correct intussusception, the parents comment that the child seems to suck on the pacifier more since the surgery. The nurse explains that sucking on a pacifier:
A. Provides an outlet for emotional tension.
B. Indicates readiness to take solid foods.
C. Indicates intestinal motility.
D. Is an attempt to get attention from the parents
Answer Key
Sucking provides the infant with a sense of security and comfort. It also is an outlet for releasing tension. The infant should not be discouraged from sucking on the pacifier. Fussiness after feeding may indicate that the infant’s appetite is not satisfied. Sucking is not manipulative in the sense of seeking parental attention.
Under which circumstance may a nurse communicate medical information without the client’s consent?
A. When certifying the client’s absence from work.
B. When requested by the client’s family.
C. When treating the client with a sexually transmitted disease.
D. When ordered by another physician.
Answer Key
Sexually transmitted diseases are communicable diseases that must be reported. The nurse is responsible for reporting these diseases to the appropriate public health agency, and otherwise maintaining the client’s confidentiality. The client’s family cannot request the release of medical information without the client’s consent. A physician’s order is not a substitute for a client’s consent to release medical information in the absence of a communicable disease.
A 22-year-old client is brought to the emergency department with his fiancée after being involved in a serious motor vehicle accident. His Glasgow Coma Scale score is 7 and he demonstrates evidence of decorticate posturing. Which of the following is appropriate for obtaining permission to place a catheter for intracranial pressure (ICP) monitoring?
A. The nurse will obtain a signed consent from the client’s fiancée because he is of legal age and they are engaged to be married.
B. The physician will get a consultation from another physician and proceed with the placement of the ICP catheter until the family arrives to sign the consent.
C. Two nurses will receive verbal consent by telephone from the client’s next of kin before inserting the catheter.
D. The physician will document the emergency nature of the client’s condition and that an ICP catheter for monitoring was placed without consent.
Answer Key
In a life-threatening emergency where time is of the essence in saving life or limb, consent is not required. This client has a Glasgow Coma Scale score of 7, which means he is comatose. The client has deteriorated to a level where he cannot be aroused, withdraws in a purposeless manner from painful stimuli, exhibits decorticate posturing, and may or may not have brain stem refl exes intact. The placement of the ICP monitor is crucial to determine cerebral blood flow and prevent herniation. The client’s fiancée cannot sign his consent because, until she is his wife or has designated power of attorney, she is not considered his next of kin. The physician should insert the catheter in this emergency. He does not need to get a consultation from another physician. When consent is needed for a situation that is not a true emergency, two nurses can receive verbal consent by telephone from the client’s next of kin.
A 69-year-old client’s daughter is asking about the follow-up evaluation for her father after his pneumonectomy for primary lung cancer. The nurse’s best response is which of the following?
A. “The usual follow-up is chest X-ray and liver function tests every 3 months.”
B. “The follow-up for your father will be a chest X-ray and a computed tomography scan of the abdomen every year.”
C. “No follow-up is needed at this time.”
D. “The follow-up for your father will be a chest X-ray every 6 months.”
Answer Key
Follow-up generally involves semiannual chest radiographs. Recurrence usually occurs locally in the lungs and may be identified on chest radiographs. Follow-up after cancer treatment is an important component of the treatment plan. Serum markers (liver function tests) have not been shown to detect recurrence of lung cancer. There are no data to support the need for an abdominal computed tomography scan.
The nurse is preparing to administer blood to a client who requires postoperative blood replacement. The nurse should use a blood administration set that has a:
A. Micron mesh filter.
B. Nonfi-ltered blood administration set.
C. Special leukocyte-poor filter.
D. Micro drip administration set.
Answer Key
All blood products should be administered through a micron mesh filter. Blood is never administered without a filter. Leukocytes can be removed by using leukocyte-poor filters, and this is recommended to decrease reactions in clients, such as hemophiliacs, who require frequent transfusions. Blood is too concentrated to administer through a micro drip set.
During the health history interview, which of the following strategies is the most effective for the nurse to use to help clients feel that they have an active role in their health care?
A. Ask clients to complete a questionnaire.
B. Provide clients with written instructions.
C. Ask clients for their description of events and for their views concerning past medical care.
D. Ask clients if they have any questions.
Answer Key One of the best strategies to help clients feel in control is to ask them their view of situations and to respond to what they say. This technique acknowledges that clients’ opinions have value and relevance to the interview. It also promotes an active role for clients in the process. The use of a questionnaire or written instructions is a means of obtaining information but promotes a passive client role. Asking whether clients have questions encourages participation, but alone it does not acknowledge their views.
The nurse is planning care for a client who chews their fingers constantly. Before applying mitten restraints, the nurse could try one of the following interventions? Select all that apply.
A. Ask the client to rub lotion over the hands every day after bathing.
B. Encourage physical activity, such as ambulation.
C. Provide frequent contacts for communication and socialization.
D. Provide family education.
E. Encourage the involvement of family and friends.
Answer Key
Socialization and communication, in addition to increased activity, are all means to aid in the prevention of self-injury. Education of family members may foster the development of strategies to prevent self-injury; hence, mitten restraints could be avoided. Applying lotion after bathing may not be appropriate when the skin is broken and not intact.