A nurse manager is planning to teach staff about critical pathways. Which of the following information should the nurse plan to include?

Nurses notes are used to create the critical pathway

Critical pathways should reduce health care costs

Critical pathways have an unlimited timeframe for completion.

Nurses should discontinue the critical pathway if variances occur

Answer and Explanation

The Correct Answer is B

Rationale:

A. Nurses notes are used to create the critical pathway: Critical pathways are developed from evidence-based clinical guidelines and best practices, not directly from nurses’ notes. While documentation may help track progress, it is not the foundation for pathway creation.

B. Critical pathways should reduce health care costs: Critical pathways standardize care for specific diagnoses, promoting timely interventions and reducing unnecessary treatments or delays. This efficiency helps lower healthcare costs while improving patient outcomes.

C. Critical pathways have an unlimited timeframe for completion: Each critical pathway includes a defined timeline with expected outcomes for each phase of care. This structure ensures care is efficient and progress is monitored closely to prevent delays or complications.

D. Nurses should discontinue the critical pathway if variances occur: Variances are deviations from the expected outcomes and are used to evaluate and adjust care. They do not justify discontinuing the entire pathway but rather indicate a need for reassessment or individualized modifications.

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Correct Answer is A

Explanation

Rationale:

A. “The client exhibits impulsive behavior.” Impulsivity is a hallmark trait of borderline personality disorder (BPD). Clients may engage in risky behaviors such as substance abuse, binge eating, or reckless driving, often in response to emotional instability and fear of abandonment.

B. “The client is overly concerned about minor details.” This behavior is more characteristic of obsessive-compulsive personality disorder, where clients show perfectionism and a rigid adherence to rules, order, and control over details.

C. “The client might act seductively.” Seductive or provocative behavior is commonly seen in histrionic personality disorder. These clients seek attention and approval through exaggerated emotional expression and flirtatiousness.

D. “The client is exceptionally clingy to others.” Clinginess and an excessive need to be taken care of are features of dependent personality disorder. These individuals have difficulty making decisions independently and fear separation or rejection.

A. Maintain the head of the client's bed at a 30° angle or higher. B. Check gastric residuals every 4 hr. C. Check placement of the feeding tube by x-ray once daily. D. Ensure the formula is cold before administration. E. Change the feeding container and tubing every 24 hr.

Correct Answer is ["A","B","E"]

Explanation

Rationale:

A. Maintain the head of the client's bed at a 30° angle or higher: Elevating the head of the bed reduces the risk of aspiration by preventing gastric contents from entering the airway, especially during and after feeding.

B. Check gastric residuals every 4 hr: Regular residual checks help assess gastric emptying and tolerance of enteral feeding. High residuals may indicate delayed gastric motility and require intervention.

C. Check placement of the feeding tube by x-ray once daily: An x-ray is used only once to confirm initial tube placement. Daily x-rays are unnecessary unless dislodgement is suspected; routine placement verification is done via pH testing or aspiration.

D. Ensure the formula is cold before administration: Cold formula can cause cramping or discomfort. It should be at room temperature before administration to promote tolerance and reduce gastrointestinal side effects.

E. Change the feeding container and tubing every 24 hr: Changing feeding equipment every 24 hours prevents microbial contamination, especially with continuous feeding, and is consistent with infection control guidelines.

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A nurse manager is planning to teach staff about critical pathways. Which of the following information should the nurse plan to include?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is developing an in-service about personality disorders. Which of the following information should the nurse include when discussing borderline personality disorder?

Correct Answer is A

Explanation

A nurse is caring for a client who is receiving continuous enteral feedings. Which of the following actions should the nurse take? (Select all that apply.)

Correct Answer is ["A","B","E"]

Explanation

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