A nurse is reviewing an electronic medical record to determine if a client’s rights have been violated by another member of the healthcare team. Which finding will the nurse identify that would indicate a violation of the client’s rights?

The client was placed on one-to-one continuous observation for a history of aggressive behavior

Physical restraints were used to prevent harm to self

The client’s belongings were searched at admission

A lack of documentation of benefits of treatment and treatment options

Answer and Explanation

The Correct Answer is D

Choice A reason: One-to-one observation for aggressive behavior is a standard safety measure to prevent harm, aligning with the right to safe care. It does not violate client rights when justified by clinical need, as it prioritizes protection without restricting autonomy unnecessarily, making it an appropriate intervention.

Choice B reason: Using physical restraints to prevent self-harm is permissible when less restrictive measures fail, aligning with the right to safety. If properly documented and justified, it does not violate rights, as mental health laws allow restraints for imminent danger, making this action compliant with client rights.

Choice C reason: Searching belongings at admission is standard in psychiatric settings to ensure safety (e.g., removing contraband). This practice, when conducted respectfully and per policy, does not violate client rights, as it prioritizes a safe therapeutic environment for all patients and staff on the unit.

Choice D reason: Lack of documentation of treatment benefits and options violates the right to informed consent. Clients must be informed about treatment rationale and alternatives to make autonomous decisions. Failure to document this breaches legal and ethical standards, undermining the client’s ability to participate in their care, making it a rights violation.

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Correct Answer is C

Explanation

Choice A reason: Neighborhood watch programs enhance community safety but do not directly address mental health needs. They lack therapeutic components to manage symptoms or prevent decompensation, which are critical for preventing readmission in clients with mental health disorders, making this factor less relevant to sustained community stability.

Choice B reason: Taking meals at a food bank addresses nutritional needs but does not directly support mental health stability. While nutrition is important, it does not provide the therapeutic interventions or coping strategies needed to manage mental health disorders and prevent relapse or hospital readmission.

Choice C reason: Participation in treatment, such as therapy or medication adherence, directly addresses mental health symptoms, improving coping skills and emotional regulation. Consistent treatment reduces relapse risk, enhances stability, and supports community integration, making it the most effective factor for preventing readmission in clients with mental health disorders.

Choice D reason: A safe living environment reduces stress and safety risks but is secondary to active treatment. Without ongoing therapy or medication, environmental safety alone cannot manage symptoms or prevent decompensation, making it less critical than treatment participation for maintaining community stability and avoiding readmission.

A. The patient is experiencing improved nutritional status B. The weight gain is expected and not clinically significant C. The patient is showing early signs of recovery from AKI D. The patient may be retaining fluid due to AKI

Correct Answer is D

Explanation

Choice A reason: Improved nutritional status could cause weight gain but is unlikely in AKI with minimal urine output. AKI patients often have anorexia or dietary restrictions, and weight gain from nutrition would not align with oliguria, which suggests fluid retention rather than increased tissue mass from improved nutrition.

Choice B reason: A 3-pound weight gain in 48 hours with minimal urine output is clinically significant in AKI, indicating fluid retention. Normal weight fluctuations are minimal, and this rapid gain, coupled with oliguria, suggests impaired kidney function, potentially leading to fluid overload complications like hypertension or pulmonary edema.

Choice C reason: Early AKI recovery involves increased urine output (diuresis phase), not minimal output. Weight gain with oliguria indicates ongoing kidney dysfunction, not recovery. Recovery would show improved glomerular filtration and urine production, reducing fluid retention, making this finding inconsistent with AKI recovery.

Choice D reason: In AKI, minimal urine output (oliguria) reflects impaired kidney filtration, leading to fluid retention. A 3-pound weight gain in 48 hours corresponds to approximately 1.5 liters of fluid, indicating fluid overload. This can cause hypertension, pulmonary edema, or heart failure, making fluid retention the most likely explanation.

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A nurse is reviewing an electronic medical record to determine if a client’s rights have been violated by another member of the healthcare team. Which finding will the nurse identify that would indicate a violation of the client’s rights?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is planning the discharge of a client with a mental health disorder. Which factor does the nurse identify as the best chance for the client to remain in the community without readmission?

Correct Answer is C

Explanation

Correct Answer is D

Explanation

The nurse is evaluating clients in the emergency department (ED) for pending mental health admissions. Which client will be admitted for involuntary hospitalization?

Which statement by a nurse may undermine a patient’s feelings and belittle the patient’s concerns?

An adult client was put in restraints after all other attempts to reduce aggression have failed. Which is required now that restraints have been instituted by the nurse?

The nurse is sitting down with a client to begin a conversation. Which position will the nurse take to convey acceptance of the client?

The nurse is performing an admission assessment for a client on the behavioral health unit with depression and anxiety. Which goal of therapeutic communication will the nurse prioritize?

The client states, “I understand that in order to leave, I must sign a request to withdraw from treatment.” What is the client’s legal status?

A nurse is talking with a patient, and 5 minutes remain in the session. The patient has been silent for most of the session. Another patient comes to the door of the room, interrupts, and says, “I really need to talk to you right now.” The nurse should: