When a nurse responds to a client's call light, the client tells the nurse that his watch is missing.

He states that he left it in the drawer of his bedside table, and now it is not there.

Later, the nurse sees an assistive personnel (AP) taking a man's watch from her pocket and putting it in her purse.

Which of the following actions should the nurse take?

Report the observation to the immediate supervisor.

Confront the AP about her theft of the client's watch.

Tell the client that the AP took his watch.

Call security before the AP leaves the building.

Answer and Explanation

The Correct Answer is A

Choice A rationale

Reporting the observation to the immediate supervisor is the most appropriate and ethical action. The nurse is a mandated reporter for such events within the healthcare setting. The supervisor, in their administrative role, is responsible for initiating a formal investigation into the matter, ensuring due process, and taking necessary disciplinary action according to institutional policy. This approach protects both the client and the nurse, who is acting on observed evidence, and maintains a chain of command.

Choice B rationale

Confronting the assistive personnel (AP) directly is an inappropriate and potentially unsafe action. This approach could escalate the situation, lead to a hostile confrontation, and create an unsafe work environment. The nurse's role is not to act as a law enforcement officer or to administer disciplinary action. The proper channel for addressing a suspected theft is through the established reporting structure, which involves informing the immediate supervisor. This maintains professional boundaries and ensures a fair and impartial investigation.

Choice C rationale

Telling the client that the assistive personnel (AP) took their watch is premature and unprofessional. The nurse has only observed the AP with a watch, but has not yet confirmed it is the client's. Making such an accusation directly to the client could be slanderous, cause emotional distress, and is not a factual statement. The proper procedure is to report the observation to the supervisor and allow the official investigation to proceed, which will determine the facts before any conclusions are drawn or communicated.

Choice D rationale

Calling security before the assistive personnel (AP) leaves the building is an excessive and premature action. The nurse's role is to report concerns to the immediate supervisor, who will then follow the proper institutional procedures, which may include contacting security if deemed necessary. Bypassing the chain of command and taking unilateral action could create a chaotic and unmanaged situation, potentially infringing on the AP's rights. The supervisor is the designated authority to manage such incidents and coordinate with other departments as needed. *.

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Correct Answer is A

Explanation

Choice A rationale

Applying petroleum jelly to the glans of the penis is an important step in the care of a newborn who has undergone a Gomco circumcision. This acts as a protective barrier to prevent the glans from sticking to the diaper, which can cause pain and disrupt the healing process. This is done with each diaper change for the first few days.

Choice B rationale

The yellow, sticky exudate that forms on the glans is a normal part of the healing process and is composed of fibrin and serum. Wiping it off can disrupt the healing tissue and increase the risk of bleeding and infection. The parent should be instructed to allow this exudate to fall off naturally.

Choice C rationale

Applying gentle pressure with a diaper is not an appropriate intervention. The area should be kept as free from pressure as possible to promote healing and reduce discomfort. Pressure could cause bleeding, pain, or damage to the delicate new tissue that is forming.

Choice D rationale

Alcohol is a harsh astringent that can cause significant pain and irritation to the sensitive, healing tissue of the glans. It can also dry out the skin, delaying the healing process. Only warm water should be used to clean the area during diaper changes. .

A. Histrionic. B. Avoidant. C. Obsessive-compulsive. D. Borderline.

Correct Answer is B

Explanation

Choice A rationale

Histrionic personality disorder is characterized by a pervasive pattern of excessive emotionality and attention-seeking behavior. Individuals with this disorder often feel uncomfortable when not the center of attention and may use dramatic, theatrical, or seductive behaviors to attract others. They are not typically withdrawn or anxious in social settings.

Choice B rationale

Avoidant personality disorder is characterized by a pervasive pattern of social inhibition, feelings of inadequacy, and hypersensitivity to negative evaluation. The client's statements of becoming "extremely anxious in social gatherings" and never feeling "good enough" for coworkers are hallmark symptoms of this disorder. They actively avoid social situations to prevent rejection.

Choice C rationale

Obsessive-compulsive personality disorder is characterized by a preoccupation with orderliness, perfectionism, and mental and interpersonal control. Individuals with this disorder are often rigid and inflexible. They are not typically described as being socially anxious due to feelings of inadequacy, but rather due to a need for control.

Choice D rationale

Borderline personality disorder is characterized by a pervasive pattern of instability in interpersonal relationships, self-image, and emotions, and marked impulsivity. While individuals with this disorder may experience intense anxiety and fear of abandonment, their core features are related to instability, not a pervasive feeling of not being "good enough" in social settings. .

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is teaching the parent of a newborn who underwent a circumcision using the Gomco method. Which of the following statements by the parent indicates an understanding of the teaching?

Correct Answer is A

Explanation

A nurse is assessing a client who states that she becomes extremely anxious in social gatherings. She tells the nurse that she never feels "good enough" for her coworkers. The nurse should identify that these findings can indicate which of the following personality disorders.

Correct Answer is B

Explanation

A nurse is teaching a newly licensed nurse about advance directives. Which of the following statements by the newly licensed nurse indicates an understanding of the teaching?

A nurse is planning care for a client who is undergoing brachytherapy with a low-dose radiation implant for treatment of prostate cancer. Which of the following interventions should the nurse include in the client's plan of care?

A nurse is teaching a newly licensed nurse about informed consent. Which of the following information should the nurse include in the teaching?

A nurse is assessing a client who has schizophrenia and is taking risperidone. Which of the following adverse effects of the medication is the priority finding for the nurse to report to the provider?

A nurse is caring for a client who is at 33 weeks of gestation, has eclampsia, and is experiencing a seizure. Which of the following actions should the nurse take following the seizure.

A nurse is preparing regular and NPH insulin in the same syringe for a client who has diabetes mellitus. Which of the following actions should the nurse take?

A nurse is part of a task force planning to audit a facility's nursing units concerning adherence to hand-hygiene protocols. Which of the following steps should the task force take first.

A nurse is replacing the dressing for a client who is postoperative following thoracic surgery. When assessing the surgical wound, which of the following findings should the nurse identify as an indication of infection?