A guard at a prison brings an injured inmate to the facility clinic. The inmate is bleeding, and the guard asks the nurse about the inmate's HIV infection status. Which of the following actions by the nurse is appropriate?

Have the guard sign a release of information form.

Tell the guard to submit an inmate inquiry form to the warden.

Complete an incident report.

Instruct the guard to ask the inmate.

Answer and Explanation

The Correct Answer is C

A.   Having the guard sign a release of information form may not be appropriate in an emergency situation, and immediate action is needed to address the injury.
B.   Telling the guard to submit an inmate inquiry form to the warden may delay necessary medical intervention in an emergency.
C.   Completing an incident report is appropriate to document the situation and the care provided It is not necessary to disclose the inmate's HIV status in the report.

D.   Instructing the guard to ask the inmate is not a proper approach to handling a medical emergency. The nurse should focus on providing immediate care to the injured inmate.

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Correct Answer is D

Explanation

A. A client with diminished vision ambulating in well-lit areas may be at risk for falling but is not at the greatest risk among the options provided.
B. A client who received a diuretic 30 min ago may experience orthostatic hypotension, which can increase the risk of falling, but it is not the highest risk.
C. A client who requires assistance with ambulation is generally at a lower risk than a client who has recently experienced a tonic-clonic seizure.
D. A client who had a tonic-clonic seizure 2 hr ago is at the greatest risk for falling due to potential residual weakness, disorientation, or postictal state following the seizure.

A. Palpate the abdomen. B. Auscultate bowel sounds. C. Offer pain medication. D. Administer an antibiotic.

Correct Answer is B

Explanation

A. Palpating the abdomen may exacerbate pain or cause discomfort, and it is not the first action in the assessment of a client with suspected appendicitis. Auscultating bowel sounds is a more appropriate initial step.
B. Auscultating bowel sounds is the priority to assess for signs of bowel obstruction or ileus, which can contribute to the client's symptoms.
C. Offering pain medication can be addressed after the initial assessment and determination of the cause of the symptoms.
D. Administering an antibiotic is premature before a diagnosis is confirmed. The priority is to assess and gather information first.

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A guard at a prison brings an injured inmate to the facility clinic. The inmate is bleeding, and the guard asks the nurse about the inmate's HIV infection status. Which of the following actions by the nurse is appropriate?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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