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 D

Explanation

Rationale:

A. Agency policies for the LPN are important but secondary to ensuring the tasks fall within the scope of practice.

B. The documented experience level of the LPN is relevant but should be considered in conjunction with the scope of practice.

C. The documented skill level of the LPN is important for assigning tasks but must align with legal scope of practice.

D. State Nurse Practice Act for the LPN is the priority criterion as it defines the legal scope of practice and ensures that tasks delegated to the LPN are within their legal and professional boundaries.

A. The client is inappropriate and is a huge fall risk B. The provider has denied this RN's requests for physical or chemical restraints C. They appear 'medically stable D. The partner is at bedside and said that their spouse is always complaining or arguing E. the ICU and progressive care unit are full F. the client is being admitted to this medical unit G. Denies pain. Sitting up in bed

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

Explanation

The nurse's documentation of the client being "inappropriate" is vague and unprofessional. Additionally, using the term "huge fall risk" without a specific assessment or plan to mitigate the risk (e.g., implementing fall precautions) is not adequate documentation. Further, the nurse’s reliance on physical or chemical restraints without exploring alternative interventions suggests a need for education on restraint use and patient safety practices.

The nurse's notes reflect a subjective description of the client's behavior as 'inappropriate' and 'complaining or arguing,' which is not objective or professional. It is important for nursing documentation to remain objective and to describe observed behaviors rather than labeling them. The statement that the client is "medically stable" should be supported by objective data rather than subjective observation, and it is important to note that mental health stability is also a crucial aspect of overall health.

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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

An RN is delegating care activities to a licensed practical nurse (LPN). Which of the following is the priority criterion the RN should consider when delegating?

Correct Answer is D

Explanation

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

Explanation

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