A nurse manager is reviewing the admission history of four adults who were admitted to the medical-surgical unit during the shift. Which of the following situations is the nurse required to disclose information to an outside agency about the client or the client's circumstances?

A young adult client admitted for acute glomerulonephritis following a viral infection

A dependent adult admitted for the treatment of a spiral fracture

A young adult client admitted for asthma and has track marks that may indicate IV drug abuse

An emancipated minor who has acute appendicitis and wants to leave the facility without treatment

Answer and Explanation

The Correct Answer is B

Rationale:

A. A young adult client admitted for acute glomerulonephritis following a viral infection does not indicate a mandatory report situation.

B. A dependent adult admitted for the treatment of a spiral fracture suggests potential abuse or neglect. As mandated reporters, nurses are required to report suspicions of abuse or neglect to the appropriate authorities.

C. A young adult client admitted for asthma and has track marks that may indicate IV drug abuse does not necessarily require mandatory reporting unless there is evidence of abuse or harm that needs to be reported.

D. An emancipated minor who has acute appendicitis and wants to leave the facility without treatment may raise concerns about the minor's capacity to make decisions, but it does not automatically necessitate reporting to an outside agency.

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

Explanation

Rationale:

A. Check the position of a client in soft wrist restraints is appropriate for an AP as it involves routine monitoring and ensuring the client's safety.

B. Accompany a client who has depression to occupational therapy is a task that can be assigned to an AP, as it involves providing support and ensuring the client's safe arrival to therapy.

C. Set limits with a client who has mania is not appropriate for an AP, as this involves therapeutic communication and behavior management, which requires nursing judgment.

D. Sit with a client who has alcohol use disorder and whose last drink was five days ago can be assigned to an AP as it involves providing a supportive presence and monitoring, but the nurse should assess for withdrawal symptoms.

E. Assess a client who has hypomania for exhaustion is a nursing responsibility that involves evaluation and judgment, making it inappropriate to delegate to an AP.

A. The physiologic status of the clients on the unit B. Social relationships between nurses working the oncoming shift C. Personal comfort level in making the assignments D. The most experienced nurse receives the more complex clients

Correct Answer is A

Explanation

Rationale:

A. The physiologic status of the clients is the most critical factor in assigning tasks, ensuring that clients with more complex needs receive appropriate care.

B. Social relationships are secondary to patient safety and quality of care.

C. Personal comfort level should not influence assignment decisions; patient care needs are the priority.

D. Assigning the most experienced nurse to complex clients is appropriate, but it should be based on client needs rather than just experience alone.

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A nurse manager is reviewing the admission history of four adults who were admitted to the medical-surgical unit during the shift. Which of the following situations is the nurse required to disclose information to an outside agency about the client or the client's circumstances?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is planning to assign care activities to the assistive personnel (AP) on her team. Which of the following activities can the nurse assign to the AP? (Select all that apply.)

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

Explanation

A charge nurse is making assignments for nursing personnel who will be caring for clients during the oncoming shift. Which of the following factors should the charge nurse consider?

Correct Answer is A

Explanation

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