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. Capillary refill time of 4 seconds is concerning but less urgent compared to immediate post-catheter removal issues.

B. Fruity breath odor in late-stage cirrhosis could indicate a metabolic issue but is less immediate than issues related to urinary output.

C. Green gastric aspirate with a pH of 5.3 is within normal range for NG tube decompression.

D. A client who has not voided 5 hours after catheter removal is at risk for urinary retention or other complications and should be assessed immediately.

A. Identify changes within the family unit that promote the client's autonomy. B. Gain 2 pounds of weight per week. C. Make positive statements about improvements in body image. D. Feel in control of her behavior.

Correct Answer is B

Explanation

Rationale:

A. Identifying changes within the family unit can be important but is not the immediate priority for medical stabilization.

B. Gaining weight is a critical goal for clients with anorexia nervosa to address their physical health and nutritional status.

C. Making positive statements about body image is helpful but secondary to the goal of weight gain.

D. Feeling in control of behavior is important for long-term recovery but is not the immediate priority compared to physical 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

A nurse is caring for four clients on a medical-surgical unit. Which of the following clients should the nurse assess first?

Correct Answer is D

Explanation

A nurse is planning care for a client who has anorexia nervosa. The nurse should make which of the following client goals the priority?

Correct Answer is B

Explanation

A nurse manager is preparing an inservice program for the nurses on the unit about the use of a new infusion pump. Which of the following teaching strategies is the most effective way to ensure that the staff can use the device correctly?

A nurse manager received a client request not to have a specific staff nurse care for her while at the acute care facility. Which of the following is the appropriate action by the nurse manager?

A nurse on a pediatric unit is caring for a child and his family. His parents define family as a husband, wife, and child. This definition is which type of family form?

A nurse manager has received information from the facility's risk management department that a former client is pursuing a lawsuit. The nurse manager should anticipate a deposition will be required during which phase of the legal process?

A nurse on a surgical unit is caring for a group of clients. Which of the following is the priority action of the nurse?

A nurse enters a client's room and finds the client pulseless. The family has requested a do-not-resuscitate (DNR) order from the provider, but he has not written the order yet. Which of the following actions should the nurse take?

A nurse is planning to delegate a task to an assistive personnel (AP). Which of the following actions should the nurse plan to take?

A charge nurse allows two nurses who are arguing about who gets to go to lunch first to go together. The charge nurse agrees to take care of both of the nurses' clients while they are at lunch. The charge nurse is demonstrating which of the following types of conflict management?