Terms in this set (175)
At the start of a counseling session with the RN, the patient C. "Is it because you feel like no one would understand what you are experiencing?"
states, "We're wasting time with these meetings. I can't trust
anyone with what's really bothering me about things I've (RAT) The nurse is demonstrating the non-therapeutic communication technique of
done." Which of the following responses should the RN verbalizing the implied, which helps clarify the implicit meaning of the patient's
provide? statement and encourages further discussion.
A. "What makes you think that?" (NOTE) (A) demonstrates the non-therapeutic communication technique of assuming
the existence of an external source of power. This allows the patient to blame
B. "These sessions are for your own good. We need to something else for behavior rather than accepting the responsibility.
continue them."
C. "Is it because you feel like no one would understand what
you are experiencing?"
D. "Perhaps you'd rather talk about that visit you had with
your sister".
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A charge nurse is observing a newly licensed RN irrigate a B. Instilling 50 mL of fluid with each irrigation
patient's ear, which is impacted with cerumen. Which of the
following actions requires the charge RN to intervene? (RAT) When irrigating a patient's ear the RN should use no more than 5 - 10 mL of
irrigating fluid at a time to decrease the chance of stimulating the vestibular nerve of
A. Visualizing the eardrum before irrigating the inner ear, which would result in N&V or dizziness.
B. Instilling 50 mL of fluid with each irrigation
C. Using firm, continuous pressure while irrigating
D. Warming the irrigation fluid to at least 37C (98F)
A charge nurse is preparing an educational session for a D. "In the event a client threatens harm to others, medications can be administered
group of new nurses to review patient rights under the law. without consent."
Which of the following statements should the RN make?
(RAT) The charge nurse should inform the participants that their primary commitment
A. "Information regarding clients should remain confidential is to the client and their priority is always to advocate for and protect their health and
until after their death." safety. During an emergency situation, if the client is threatening harm to self or
others, medications can be administered without the client's consent and without a
B. "Failure to report suspected maltreatment or neglect of a court order.
disabled adult is a felony in all states."
(NOTE) Because laws vary from state to state, nurses should become familiar with the
C. "As long as client identity is disguised, their health requirements as it relates to reporting neglect or maltreatment of clients. The nurse
information can be shared between professionals on the should inform the participants that in most states failure to report the suspected
internet." neglect, physical maltreatment, or exploitation of a disabled adult results in a
misdemeanor charge - (B) is incorrect.
D. "In the event a client threatens harm to others,
medications can be administered without consent."
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A charge nurse is teaching the patient how to identify the C - conduct d/o before age 15yr, charming
difference between antisocial personality d/o and narcissistic A - arrests
personality disorder. Please use the mnemonic CALLOUS L - lies
MAN to describe antisocial personality d/o. L - lacks a superego & empathy for others
O - obligations not honored
U - unstable, can't plan ahead
S - sense of entitlement, seductive, not safe
M - manipulative, $ problems & irresponsible
A - aggressive and assaultive
N - not calm, actions are impulsive
A charge RN is teaching a group of unit nurses about the D. A patient who has a Hx of MRSA can still transmit the infection
policy for patients who have a history of MRSA. Which of
the following information should the nurse include?
A. A patient who has a history of MRSA will need
antibiotics
B. A patient who has a Hx of MRSA can develop immunity
to the infection
C. A patient who has a Hx of MRSA requires a protective
environment
D. A patient who has a Hx of MRSA can still transmit the
infection
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During a group session on a osych unit, the nurse leader Ask the patient to speak privately with the nurse after the meeting
observes that one of the patients frequently interrupts the
session. Which of the following nursing actions is the most
appropriate for this situation?
During morning rounds a RN finds a patient who has C. Assess the client for evidence of a perceptual disturbance.
schizophrenia trembling and tearful in their bed. The patient
reports that a bomb was placed in their room by a family (RAT) The nurse should assess the situation to determine if the client is hallucinating
member during visiting hours. Which of the following or misperceiving external stimuli, also known as experiencing illusions.
actions should the RN take ?
(NOTE) Trying to convince the client that there is not a bomb in their room negates
A. Ask the client to identify the bomb in the room. the client's experience - so convincing the patient that there is no bomb in their room
is the incorrect action to take
B. Initiate disaster protocols per facility policies and
procedures.
C. Assess the client for evidence of a perceptual disturbance.
D. Convince the client that there is no bomb in their room.
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