A nurse working in an emergency department is caring for a group of clients. Which of the following clients should the nurse report for suspected maltreatment?

A toddler who cries whenever their parent enters the examination room

An adolescent who was admitted and refuses to speak to their parents

A preschooler who was previously toilet trained and now requires diapers in the hospital

A school-age child who has several abrasions on their lower legs

Answer and Explanation

The Correct Answer is D

Choice A Reason:
A toddler who cries whenever their parent enters the examination room is incorrect. Toddlers may exhibit separation anxiety or fear of medical procedures, which is a common behavior in this age group.
Choice B Reason:
An adolescent who was admitted and refuses to speak to their parents is incorrect. Adolescents may exhibit behaviors such as withdrawal or reluctance to communicate with parents due to developmental changes, stress, or other factors unrelated to maltreatment.
Choice C Reason:
A preschooler who was previously toilet trained and now requires diapers in the hospital is incorrect. Regression in toileting skills is common in preschoolers during times of stress or illness, such as hospitalization. It does not necessarily indicate maltreatment but may be a response to the unfamiliar environment or medical condition.
Choice D Reason:
A school-age child who has several abrasions on their lower legs is correct. Abrasions on a school-age child's lower legs could potentially indicate physical abuse or neglect, especially if they are unexplained or inconsistent with the child's reported activities. Reporting such findings for further investigation is essential to ensure the safety and well-being of the child.

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Correct Answer is D

Explanation

Choice A Reason:
Completing an incident report is inappropriate. While completing an incident report is important for documenting any errors or deviations from the standard of care, it should not be the first action taken. Assessing the client's condition takes precedence to ensure their immediate safety and well-being.
Choice B Reason:
Notifying the provider is inappropriate. Notifying the provider may be necessary, but it should not be the first action taken. Initially, the nurse should assess the client's condition to determine if any adverse effects have occurred as a result of the additional medication dose.
Choice C Reason:
Informing the nursing supervisor is inappropriate. Informing the nursing supervisor may be appropriate, especially if further actions or investigations are needed. However, the immediate priority is to assess the client's condition to ensure their safety.
Choice D Reason:
Observing the client's condition is appropriate. The nurse should first assess the client's condition to determine if any adverse effects have occurred due to the additional medication dose. This assessment helps identify any immediate concerns that require intervention. Based on the client's condition, further actions such as notifying the provider or completing an incident report may be warranted. However, observing the client's condition is the initial and most immediate action to take.

A. Demonstrate the proper client transfer technique for the AP. B. Instruct the AP to request assistance when unsure about a task. C. Refer the AP to the facility procedure manual. D. Help the AP assist the client with the transfer.

Correct Answer is D

Explanation

Choice A Reason:
Demonstrating the proper client transfer technique for the AP, could be beneficial after ensuring the immediate safety of the client. However, providing immediate assistance to the client is the priority.
Choice B Reason:
Instructing the AP to request assistance when unsure about a task, is important for promoting a culture of safety and collaboration. However, in this scenario, the immediate focus is on assisting the client.
Choice C Reason:
Referring the AP to the facility procedure manual, may be helpful for providing additional guidance and education on proper techniques. However, in the moment, the nurse manager should prioritize immediate action to assist the client.
Choice D Reason:
Helping the AP assist the client with the transfer is correct. When a nurse manager observes an assistive personnel (AP) incorrectly performing a task such as transferring a client, the first priority is ensuring the safety and well-being of the client. Therefore, the nurse manager should intervene immediately to provide assistance and ensure that the client is transferred safely.

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A nurse working in an emergency department is caring for a group of clients. Which of the following clients should the nurse report for suspected maltreatment?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is reviewing the medication administration record of a client and notices that an additional dose of medication has been administered. Which of the following actions should the nurse take first?

Correct Answer is D

Explanation

A nurse manager observes an assistive personnel (AP) incorrectly transferring a client to the bedside commode. Which of the following actions should the nurse take first?

Correct Answer is D

Explanation

A nurse is preparing a client for surgery. The client expresses concern that someone might steal her purse during the procedure. Which of the following actions should the nurse take?

A nurse in the emergency department is preparing to care for a client who arrived via ambulance. The client is disoriented and has a cardiac arrhythmia. Which of the following actions should the nurse take?

A nurse is orienting a newly licensed nurse on the neurological unit. Which of the following clients should the nurse assign to the newly licensed nurse?

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A charge nurse is evaluating a newly licensed nurse and presents a performance improvement plan to the nurse for remediation. Which of the following outcomes should indicate to the charge nurse that the plan has been effective?

a

A nurse manager is discussing responsibilities of the nurse manager role with a group of newly licensed nurses. Which of the following responsibilities should the nurse include? (Select all that apply.)

The primary nurse asks another nurse to assist in checking a client for an apical-radial pulse deficit. One nurse counts an apical pulse of 72 beats/minute while the other nurse counts a radial pulse of 88 beats/minute. Which action should the primary nurse take?