PROFESSIONAL ADJUSTMENT AND NURSING CARE MANAGEMENT PRACTICE EXAM ANSWER KEY WITH RATIONALES 1. The nurse is explaining the Bill of Rights for psychiatric patients to a client who has voluntarily sought admission to an inpatient psychiatric facility. Which of the following rights should the nurse include in the discussion? Select all that apply: __Right __Right __Right __Right __Right __Right
to to to to to to
select health care team members refuse treatment a written treatment plan obtain disability confidentiality personal mail
RATIONALE: An inpatient client usually receives a copy of the Bill of Rights for psychiatric patients, where they would find options 2, 3, 5, and 6 in writing. However, a client in an inpatient setting can't select health team members. A client may apply for disability as a result of a chronic, incapacitating illness; however, disability isn't a patient right, and members of a psychiatric institution don't decide who should receive it. 2. In the emergency department, a client reveals to the nurse a lethal plan for committing suicide and agrees to a voluntary admission to the psychiatric unit. Which information will the nurse discuss with the client to answer the question, "How long do I have to stay here?" Select all that apply: __"You may leave the hospital at any time unless you are suicidal." __"Let's talk more after the health team has assessed you." __"Once you've signed the papers, you have no say." __"Because you could hurt yourself, you must be safe before being discharged." __"You need a lawyer to help you make that decision." __"There must be a court hearing before you leave the hospital." RATIONALE: A person who is admitted to a psychiatric hospital on a voluntary basis may sign out of the hospital unless the health care team determines that the person is harmful to himself or others. The health care team evaluates the client's condition before discharge. If there is reason to believe that the client is harmful to himself or others, a hearing can be held to determine if the admission status should be changed from voluntary to involuntary. Option 3 is incorrect because it denies the client's rights; option 5 is incorrect because the client doesn't need a lawyer to leave the hospital; and option 6 is incorrect because a hearing isn't mandated before discharge. A hearing is held only if the client remains unsafe and requires further treatment. 3. The nurse has developed a relationship with a client who has an addiction problem. Which information would indicate that the therapeutic interaction is in the working stage? Select all that apply: __The client addresses how the addiction has contributed to family distress.
__The __The __The __The __The
client client client client client
reluctantly shares the family history of addiction. verbalizes difficulty identifying personal strengths. discusses the financial problems related to the addiction. expresses uncertainty about meeting with the nurse. acknowledges the addiction's effects on the children.
RATIONALE: Options 1, 3, and 6 are examples of the nurse-client working phase of an interaction. In the working phase, the client explores, evaluates, and determines solutions to identified problems. Options 2, 4 and 5 address what happens during the introductory phase of the nurse-client interaction. 4. If parents or legal guardians aren't available to give consent for treatment of a life-threatening situation in a minor child, which of the following statements is most accurate? A. onsent may be obtained from a neighbor or close friend of the family. B. Consent may not be needed in a life-threatening situation. C. Consent must be in the form of a signed document; therefore, parents or guardians must be contacted. D. Consent may be given by the family physician. RATIONALE: In emergencies, including danger to life or possibility of permanent injury, consent may be implied, according to the law. In some books, sabi, ung attending physician sa ER na ung mag-aako ang consent. Obviouslly, wala dun ang family physician kc emergency nga. Parents have full responsibility for the minor child and are required to give informed consent whenever possible. Verbal consent may be obtained. 5. You're admitting a 15-month-old boy who has bilateral otitis media and bacterial meningitis. Which room arrangements would be best for this client? A. In isolation off a side hallway B. A private room near the nurses' station C. A room with another child who also has meningitis D. A room with two toddlers who have croup RATIONALE: With meningitis, the child should be isolated for the first day but be close to where he can be observed frequently. In isolation off a side hallway is too far away for frequent observation. Putting the client in a room with another child who has meningitis or with two toddlers who have croup present an infectious hazard to the other children. 6. Which of the following points should a team leader consider when delegating work to team members in order to conserve time? A. Assign unfinished work to other team members. B. Explain to each team member what needs to be done. C. Relinquish responsibility for the outcome of the work. D. Assign each team member the responsibility to obtain dietary trays. RATIONALE: When all team members know what needs to be done, they can work together on the most efficient plan for accomplishing necessary tasks. Delegation can be flexible, ranging from telling a staff member exactly what needs to be done and how to do it to allowing team members some freedom to decide how best to carry out the tasks. Assigning unfinished work to other team members and assigning each team member the responsibility to obtain dietary trays don't allow for input from team members. It's the team leader's job to maintain responsibility for the outcome of a task.
7. The nurse is caring for a client admitted to the emergency department after a motor vehicle accident. Under the law, the nurse must obtain informed consent before treatment unless: A. the client is mentally ill. B. the client refuses to give informed consent. C. the client is in an emergency situation. D. the client asks the nurse to give substituted consent. RATIONALE: The law doesn't require informed consent in an emergency situation when the client is unable to give consent and no next of kin is present (NCLEX concept ito, sa Philippines, ang attending doctor sa ER na ang magcoconsent. A mentally competent client may refuse or revoke consent at any time. Even though a client who is declared mentally incompetent can't give informed consent, mental illness doesn't by itself indicate that the client is incompetent to give informed consent. Although the nurse may act as a client advocate, the nurse can never give substituted consent. CBQ ito. 8. The nurse is assigned to care for an elderly client who is confused and repeatedly attempts to climb out of bed. The nurse asks the client to lie quietly and leaves her unsupervised to take a quick break. While the nurse is away, the client falls out of bed. She sustains no injuries from the fall. Initially, the nurse should treat this occurrence as: A. a quality improvement issue. B. an ethical dilemma. C. an informed consent problem. D. a risk-management incident. RATIONALE: The nurse should treat this episode as a risk-management incident; her immediate responsibility is to fill out an incident report and notify the risk manager. Quality improvement and ethics aren't the nurse's initial concerns. The facility may choose to look at these types of problems and make changes to deliver a higher standard of care institutionally. Informed consent isn't a relevant issue in this incident 9. The nurse receives an assignment to provide care to 10 clients. Two of them have had kidney transplantation surgery within the last 36 hours. The nurse feels overwhelmed with the number of clients. In addition, the nurse has never cared for a client who has undergone recent transplantation surgery. What's the appropriate action for the nurse to take? A. Speak to the manager and document in writing all concerns related to the assignment. B. Refuse the assignment. C. Ignore the assignment and leave the unit. D. Trade assignments with another nurse. RATIONALE: When a nurse feels incapable of performing an assignment safely, the appropriate action is to speak to the manager or nurse in charge. Bawal magmarunong lalo na sa patient care. The nurse should also document the concerns in writing and ask that the assignment be changed. In the event that the manager chooses to leave the assignment as given, the nurse should accept the assignment. The nurse should never abandon the assigned clients by leaving the workplace or asking another nurse to care for them. The nurse may, however, refuse to perform a task outside the scope of practice.
10. The nurse works with a colleague who consistently fails to use standard precautions or wear gloves when caring for clients. The nurse calls the colleague's attention to these oversights. The colleague tells the nurse that standard precautions and gloves aren't necessary unless the client is known to have tested positive for the human immunodeficiency virus. What's the most appropriate action for the nurse to take? A. Ignore it because it isn't directly the nurse's problem. B. Document the problem in writing for the manager. C. Talk to other staff members to ascertain their practices. D. Instruct the clients to remind this colleague to wear gloves. RATIONALE: The nurse has spoken to her colleague under the appropriate circumstances and the behavior hasn't changed. Therefore, the appropriate action is to bring the problem to the manager's attention. It's unproductive to talk with other staff members about the situation because they don't have the authority to bring the colleague's practice into compliance. The nurse should never point out to a client that another staff member's practice isn't meeting standards. 11. An adult client is diagnosed with acquired immunodeficiency syndrome. The nurse who is caring for the client is also his friend. The nurse tells the client's parents about the diagnosis; after all, they know their son is the nurse's friend. Several weeks later, the nurse receives a letter from the client's attorney stating that the nurse has committed an intentional tort. Which intentional tort has this nurse committed? A. Fraud B. Defamation of character C. Assault and battery D. Breach of confidentiality RATIONALE: A nurse shouldn't disclose confidential information about a client to a third party who has no legal right to know; doing so is a breach of confidentiality. Defamation of character is injuring someone's reputation through false and malicious statements. Assault and battery occurs when the nurse forces a client to submit to treatment against the client's will. A nurse commits fraud when she misleads a client to conceal a mistake she made during treatment. CBQ ito. 12. A nurse accidentally administers 40 mg of propranolol (Inderal) to a client instead of 10 mg. Although the client exhibits no adverse reactions to the larger dose, the nurse should: A. call the facility's attorney. B. inform the client's family. C. complete an incident report. D. do nothing because the client's condition is stable. RATIONALE: The nurse should file an incident report. Incident reports highlight areas of potential liability. It's then the risk manager's responsibility to notify the facility's attorney if the incident is believed to be serious. The risk manager, in consultation with the physician and facility administrator, will decide who should inform the family of the error. The quality assurance coordinator may choose to use such incidents when trying to improve the quality of care received by clients in a particular facility. Taking no action isn't an acceptable option. CBQ ito. 13. The nurse is assigned to care for a postoperative client who has diabetes mellitus. During the assessment interview, the client reports that he's impotent and says that he's concerned about its effect on his marriage. In planning this client's care, the most appropriate intervention would be to:
A. encourage the client to ask questions about personal sexuality. B. provide time for privacy. C. provide support for the spouse or significant other. D. suggest referral to a sex counselor or other appropriate professional. RATIONALE: The nurse should refer this client to a sex counselor or other professional. Making appropriate referrals is a valid part of planning the client's care. The nurse doesn't normally provide sex counseling. 14. The nurse is assigned to care for eight clients. Two nonprofessionals are assigned to work with the nurse. Which statement is valid in this situation? A. The nurse may assign the two nonprofessionals to work independently with a client assignment. B. The nurse is responsible to supervise assistive personnel. C. Nonprofessionals aren't responsible for their own actions. D. Nonprofessionals don't require training before they work with clients. RATIONALE: Assistive personnel may not be assigned to care for clients without the supervision of a professional nurse. The nurse doesn’t delegate responsibility, keep in mind respondeat superior. It's essential that assistive personnel understand that they're responsible for their own actions. Assistive personnel must be adequately trained to perform all tasks they're assigned to perform. 15. Each state has guidelines that regulate the different levels of nursing : licensed practical or vocational nurse, registered nurse, or advanced practice nurse. Legal guidelines outlining the scope of practice for nurses are known as: A. consent to treatment. B. client's bill of rights. C. nurse practice acts. D. licensure requirements. RATIONALE: Each state has a nurse practice act that defines the scope of nursing practice within the state. Consent to treatment refers to informed consent for a treatment or procedure. The client's bill of rights defines the rights of clients. Licensure requirements are constructed by the state board of nursing to set standards for receiving a nursing license. CBQ ito. 16. A client is dissatisfied with his hospitalization. He decides to leave against medical advice and refuses to sign the paperwork. The nurse's next course of action is to: A. detain him until he signs the paperwork. B. detain him until his physician arrives. C. call security for assistance. D. let him leave. RATIONALE: The nurse is obligated to let him leave. Detaining him in any form is a violation of the patient's bill of rights. 17. A nurse needs assistance transferring an elderly, confused client to bed. The nurse leaves the client to find someone to assist her with the transfer. While the nurse is gone, the client falls and hurts herself. The nurse is at fault because she hasn't:
A. properly educated this client about safety measures. B. restrained the client. C. documented that she left the client. D. arranged for continual care of the client. RATIONALE: By leaving the client, the nurse is at fault for abandonment. The better course of action is to turn on the call bell or elicit help on the way to the client's room. Never ever leave a client na at risk for injury alone! Educating the client about safety measures doesn't alleviate the nurse from responsibility for ensuring the client's safety. The nurse can't restrain the client without a physician's order and restraints won't ensure the client's safety. Documenting that she left the client doesn't excuse the nurse from her responsibility for ensuring the client's safety. 18. When prioritizing a client's care plan based on Maslow's hierarchy of needs, the nurse's first priority would be: A. allowing the family to see a newly admitted client. B. ambulating the client in the hallway. C. administering pain medication. D. placing wrist restraints on the client. RATIONALE: In Maslow's hierarchy of needs, pain relief is on the first layer. Activity is on the second layer. Safety is on the third layer. Love and belonging are on the fourth layer. 19. When developing a therapeutic relationship with a client, the nurse should begin preparing the client for termination of the relationship: A. at discharge. B. during the first meeting. C. at the midpoint of the relationship. D. when the client demonstrates the ability to function independently. RATIONALE: When initiating a therapeutic relationship with a client, preparation for termination of the relationship should begin during the first meeting. For example, the nurse should introduce herself to the client and tell him exactly when she'll be involved in his care. This sets the boundaries of the relationship. In the middle and at discharge of care, the relationship may be too involved to end abruptly without warning. The client's ability to function independently isn't the deciding factor in preparing the client for the termination of the therapeutic relationship. CBQ ito. 20. To be effective, a clinical nurse-manager in a managed care environment must: A. expect all staff to accept change. B. go along with a proposed change. C. be a catalyst for change. D. document staff nurses' reactions to change. RATIONALE: The clinical nurse-manager is responsible for making things happen, not just letting things happen. She must be more than a role model who goes along with change , she must also encourage change and support staff during change. Documentation of the nurses' reactions to change can be threatening and serves no purpose in helping change to occur. 21. In community-based nursing, primary responsibility for decisions related to health care belongs to the:
A. nurse. B. client. C. health care team. D. physician. RATIONALE: The client is primarily responsible for health care decisions in community-based nursing. The nurse assists with monitoring of health treatment and teaching and intervenes only as needed after assessing the client's ability to follow a regimen. The health care team collaborates on decisions related to treatment. The physician dictates medical orders related to treatment and medication. 22. A client became seriously ill after a nurse gave him the wrong medication. After his recovery, he files a lawsuit. Who is most likely to be held liable? A. No one because it was an accident B. The hospital C. The nurse D. The nurse and the hospital RATIONALE: Nurses are always responsible for their actions. The hospital is liable for negligent conduct of its employees within the scope of employment. Consequently, both the nurse and the hospital are liable. Although the mistake wasn't intentional, standard procedure wasn't followed. CBQ ito. 23. The nurse is providing care for a client who underwent mitral valve replacement. The best example of a measurable client outcome goal is to: A. change his own dressing. B. walk in the hallway. C. walk from his room to the end of the hall and back before discharge. D. eat a special diet. RATIONALE: Walking from his room to the end of the hall and back before discharge is a specific, measurable, attainable, timed goal. It's also a client-oriented outcome goal. Having the client change his own dressing is incomplete and not as significant. Just walking in the hall isn't measurable. The need for a special diet isn't evident in this case. 24. A client with end-stage liver cancer tells the nurse he doesn't want extraordinary measures used to prolong his life. He asks what he must do to make these wishes known and legally binding. How should the nurse respond to the client? A. Tell him that it's a legal question beyond the scope of nursing practice. B. Give him a copy of the client's bill of rights. C. Provide information on active euthanasia. D. Discuss documenting his wishes in an advance directive. RATIONALE: Advance directives give a competent client control over his situation and a legal forum in which to express his wishes about his care. Discussion of advance directives isn't outside the scope of nursing practice. The client's bill of rights involves multiple client rights and doesn't provide detailed information about advance directives. Active euthanasia is illegal. CBQ ito.
25. While admitting a client with pneumonia, the nurse notes multiple bruises in various stages of healing. The client has Alzheimer's disease and a history of multiple fractures. Legally, the most important action for the nurse to take is to: A. B. C. D.
document findings thoroughly. question the client about the bruising. inform appropriate local authorities. tell the client's physician.
RATIONALE: This client may be experiencing elder abuse based on her history and symptoms. Authorities to be notified may include local social service or law enforcement agencies. The nurse should also document findings and include illustrations to support the assessment. The client with Alzheimer's disease may not be able to accurately inform the nurse about what happened. Reporting findings to the physician may not be sufficient for fulfilling the nurse's legal responsibility. 26. The nurse is providing care for a client with multiple myeloma, a disorder characterized by episodes of remissions and exacerbations. Which resource can best help the client adapt to the disease? A. B. C. D.
The client's family Pastoral care Support group Hospice care
RATIONALE: Support groups consist of clients with the same diagnoses who share experiences of the disease with each other. Sharing experiences helps the client understand disease-related problems and gives him a forum in which he can vent his feelings, which are usually similar to those of the group. The client's family and clergy, although supportive, can't share similar disease experiences. Hospice care is usually implemented late in the disease, at the end of life. 27. A client with brain cancer is deteriorating and the prognosis is poor. The client meets brain-death criteria. Which nursing intervention is most appropriate at this time? A. B. C. D.
Approach the client's family about organ donation. Make the decision to withdraw life support. Sedate the client. Talk to the staff about their feelings.
RATIONALE: The most appropriate nursing intervention is to discuss organ donation with the family. The decision to withdraw life isn't within a nurse's scope of practice. Because the client is brain-dead, he doesn't need sedation. Although talking to the staff is a viable strategy for staff decompression, it isn't the first action to take. Ito ay controversial na tanong! Madaming nag-away na lecturers because of this. 28. A client is scheduled to have a descending colostomy. He's very anxious and has many questions concerning the surgical procedure, care of a stoma, and lifestyle changes. It would be most appropriate for the nurse to make a referral to which member of the health care team? A. B. C. D.
Social worker Registered dietitian Occupational therapist Enterostomal nurse therapist
RATIONALE: An enterostomal nurse therapist is a registered nurse who has received advanced education in an accredited program to care for clients with stomas. The enterostomal nurse therapist can assist with selection of an appropriate stoma site, teach about stoma care, and provide emotional support. Social workers provide counseling and emotional support, but they can't provide preoperative and postoperative teaching. A registered dietitian can review any dietary changes and help the client with meal planning. The occupational therapist can assist a client with regaining independence with activities of daily living. 29. A 92-year-old client with prostate cancer and multiple metastases is in respiratory distress and is admitted to a medical unit from a skilled nursing facility. His advance directive states that he doesn't want to be placed on a ventilator or receive cardiopulmonary resuscitation. Based on the client's advance directive, which intervention should the nursing care plan include? A. B. C. D.
Check on the client once per shift. Provide mouth and skin care only if the family requests it. Turn the client only if he's uncomfortable. Provide emotional support and pain relief.
RATIONALE: When advance directives state that a client doesn't want lifeprolonging interventions, nursing care focuses on providing emotional and spiritual support and comfort measures. The client still needs to be checked regularly. The client and family shouldn't feel as if they've been abandoned. Providing mouth and skin care makes the client more comfortable. Turning the client provides comfort and prevents potentially painful complications such as pressure ulcers. 30. The registered nurse has an unlicensed assistant working with her for the shift. When delegating tasks, the registered nurse understands that the unlicensed assistant: A. B. C. D.
interprets clinical data. collects clinical data. is trained in the nursing process. can function independently.
RATIONALE: Unlicensed personnel make observations, collect clinical data, and report findings to the nurse. The registered nurse has learned critical thinking skills and is able to interpret the clinical findings. Unlicensed assistants are trained to perform skills, they don't learn the nursing process. Unlicensed assistants don't function independently, they're assigned tasks by a registered nurse who retains overall responsibility for the client. Other nursing responsibilities when delegating tasks to unlicensed assistants include knowing the institutions policies regarding delegation, knowing the assistant's training, knowing the client's needs, receiving frequent updates from the assistant, asking specific questions, and making frequent rounds of clients. 31. A nurse on a medical-surgical floor is making assignments for an 8-hour shift. Which of the following considerations has the highest priority? A. B. C. D.
Complexity of care required Age of the clients Skills of the assigned personnel The number of clients
RATIONALE: The nurse is legally responsible for assigning personnel according to skill level. All of the other factors are important but don't take priority.
32. The nurse is caring for a homeless client with active tuberculosis. The client is almost ready for discharge; however, the nurse is concerned about the client's ability to follow the medical regimen. Which intervention will best ensure that the client complies with treatment? A. B. C. D.
Referring the client to a social worker for discharge planning Providing individualized client education Having the client attend a formal education session Attempting to contact a member of the client's family to provide assistance
RATIONALE: Referring the client to a health care professional with knowledge of community resources is the best intervention to ensure compliance in a homeless client. Educating the client about his condition may help, but basic needs for shelter, food, and clothing must be met first. Providing formal education and attempting to contact family members are inappropriate when seeking to help a homeless client. 33. The nurse is following a critical pathway to help a client who underwent hip replacement surgery meet specific objectives. What's a critical pathway? A. A nursing care plan that helps the nurse to decide which intervention to perform first B. A multidisciplinary care plan that helps the nurse to use a variety of critical interventions C. A standardized care plan that lists basic interventions for the nurse to use with every client D. A clinical management tool that organizes the major interventions for a multidisciplinary health care team RATIONALE: Critical pathways are management tools developed for particular types of cases or conditions. They set forth expectations for interventions, outcomes, and client progression. Elements of the nursing care plan are commonly folded into the critical pathway. The descriptions of standardized and multidisciplinary plans of care don't adequately describe the critical pathway. Because the critical pathway is standardized and multidisciplinary, the nurse may need to develop a separate care plan to document nursing diagnoses for an individual client. 34. A train accident sends a large number of injured passengers to the hospital. The hospital's disaster plan is put into effect. Which one of the following nursing actions will best serve the hospital in a disaster situation? A. The nurse should know the hospital's disaster plan and what's expected of her during a disaster. B. During a disaster, the nurse should volunteer to help where she thinks assistance is most needed. C. The nurse should offer advice about how to keep the operation running smoothly. D. If told to do so, the nurse should perform tasks that are beyond her scope of practice. RATIONALE: Before a disaster occurs, the nurse should know how the hospital's disaster plan works and what she'll be required to do in a disaster. During a disaster, the charge nurse will assign staff to areas where the needs are; therefore, a nurse may find herself performing tasks outside of her usual practice. This practice is permitted if the nurse has the knowledge, skill, and comfort level to perform assigned
tasks. However, the nurse should never perform activities outside of the nurse's scope of practice as outlined in the state's nurse practice act. 35. The nurse-manager of a hospital unit holds monthly staff meetings. During these meetings, she maintains control over the meeting and agenda, resists consensus decision making, and uses discipline and coercion to elicit desired behavior from staff. This manager uses what type of leadership style? A. B. C. D.
Autocratic Democratic Participative Laissez-faire
RATIONALE: Autocratic leaders obtain power with a group by maintaining control over the group. Democratic leaders share power by allowing consensus decision making and distribution of power. Participative leadership is another term for democratic leadership. Laissez-faire leaders maintain no control over the group; decision making is unstructured and commonly performed by an unofficial leader of the group. CBQ ito, make sure that you know this by heart, kinda of leadership and for what situations xa applicable. 36. The registered nurse of a hospital unit is acting as charge nurse. The charge nurse's responsibility is to delegate client care appropriately to the licensed practical nurse (LPN) and the nurse's aide. Delegation of activities should be primarily based on which factors? A. Whether the LPN or nurse's aide provided care for the client before B. The staff member whose turn it is to perform certain, less pleasant tasks C. The job description and experience level of the LPN and the aide D. The staff member who volunteers to perform the various tasks RATIONALE: The primary considerations related to appropriate and effective care delegation are the job descriptions of the assistive staff members and their levels of expertise. Both factors must be considered together, neither in isolation. The other options identify factors that may help determine client care assignments, but only after considering job description and experience levels. 37. A task force is formed to analyze institutional problems, such as inadequate staffing and a rise in the number of negative evaluations from clients. During the meeting, members express their concerns, disagree over the most significant factors contributing to these problems, and compete for influence over the group. Which of the following four stages of group development does their behavior represent? A. B. C. D.
Forming Storming Norming Performing
RATIONALE: Storming refers to the stage when resistance to group influence occurs and the objectives of the group aren't yet clearly established. Forming is the first stage, when the members of the group first meet. During the norming stage, which occurs after storming, consensus begins to evolve, cohesion and norms develop, and conflict and resistance are resolved. Performing is the stage when the group focuses on the task at hand and constructive group efforts improve task performance.
38. A client in the final stages of terminal cancer tells his nurse, "I wish I could just be allowed to die. I'm tired of fighting this illness. I've lived a good life. I continue my chemotherapy and radiation treatments only because my family wants me to." What's the nurse's best response? A. "Would you like to talk to a psychologist about your thoughts and feelings?" B. "Would you like to talk to your minister about the significance of death?" C. "Would you like to meet with your family and your physician about this matter?" D. "I know you are tired of fighting this illness, but death will come in due time." RATIONALE: The nurse has a moral and professional responsibility to advocate for clients who experience decreased independence, loss of freedom of action, and interference with their ability to make autonomous choices. Coordinating a meeting between the physician and family members may allow the client an opportunity to express his wishes and promote awareness of his feelings, as well as influence future care decisions. All other options are inappropriate. Haler!! Lalo na ung option D. 39. The nurse works in a managed-care environment. The nurse is expected to be oriented to which of the following criteria? A. B. C. D.
Performing tasks in the shortest time possible Adhering to client preferences Problem solving and time management Quality of care and cost-containment
RATIONALE: Managed care principles mandate the most efficient use of limited resources; therefore, quality of care and cost-containment are the main issues. Nurses must look for the most cost-effective method of achieving a desired outcome without compromising quality. Problem solving and time management are skills used to implement the care plan, but aren't unique to the managed care environment. Performing tasks quickly doesn't always achieve quality care. Adhering to client preferences isn't a guiding principle. 40. A client asks to be discharged from the health care facility against medical advice (AMA). What should the nurse do? A. B. C. D.
Take measures to prevent the client from leaving. Ask the client to sign an AMA form. Call a security guard to help detain the client. Notify the physician.
RATIONALE: If a client requests discharge AMA, the nurse should notify the physician immediately. If the physician can't convince the client to stay, the physician will ask the client to sign an AMA form. This form releases the hospital from legal responsibility. If the physician isn't available, the nurse should obtain the client's signature on the AMA form. A client who refuses to sign the form shouldn't be detained; forced detention violates the client's rights. After the client leaves, the nurse should document the incident thoroughly and notify the physician that the client has left. CBQ ito. 41. The nurse is caring for a client with renal failure who requires peritoneal dialysis. The nurse doesn't feel comfortable performing the procedure. What would be the most appropriate action for the nurse to take?
A. Omit the procedure and tell the next nurse in report that she'll need to perform the dialysis. B. Ask the nursing supervisor for assistance in using the equipment. C. Ask the client how to use the equipment. D. Perform the procedure to the best of her ability, utilizing her knowledge of basic health principles. RATIONALE: When a nurse is unsure about a procedure or piece of equipment, she should tell the nursing supervisor that she isn't comfortable and ask for assistance with the task. Bawal na bawal magmarunong and maglider-lideran lalo na sa Area wherein everything you do has direct impact on the client. A nurse must always be prudent, therefore, pick options wherein safety is also addressed. If appropriate training or assistance isn't available, the nurse should ask for a different assignment. The procedure shouldn't be omitted for the shift because this could lead to serious complications for the client. The nurse should never perform a procedure that she doesn't feel prepared to perform. 42. A registered nurse suspects that another nurse has been drinking. She smells alcohol on the nurse's breath and notes slurred speech. What's the best course of action for the registered nurse to take? A. Cover for the nurse because the profession depends on loyalty from colleagues. B. Call the police and ask them to arrest the nurse because she's endangering the lives of clients. C. Tell the nurse she has one more chance, but if she drinks on duty again she'll be reported. D. Immediately notify the nursing supervisor. RATIONALE: A nurse who suspects another nurse of impaired practice has a duty to report the colleague to the nursing supervisor, not the police. A nurse who fails to report an impaired nurse may face disciplinary action. The nurse shouldn't cover for an impaired nurse or give her one more chance. These actions place clients at risk, place the nurse at risk for disciplinary action, and prevent the impaired nurse from receiving help. Remember, pantay lang kau ng level ng co staff nurse mo, you don’t have the authority na maglider-lideran amd pagsabihan xa. should:
43. When documenting care in a client's medical record, the nurse A. B. C. D.
record the nurse's interpretation of data. correct a mistake using a correcting fluid. record the time and date for all entries. leave blank spaces to record information at a later time, if necessary.
RATIONALE: All entries in the medical record should include the time and date they were written. The nurse should document observations and measurements, but avoid giving an interpretation of the data, kc the nurse’s interpretation is considered subjective and dapat, objective data lang dinodocument. Correcting fluid is never used to correct an error, hahaha! Kc uso ngaun micropore (jowk). When a mistake in documentation is made, the nurse should draw a single line through the entry, write the word error next to it, and sign her name; otherwise, it may appear as if a nurse is trying to alter or hide information. Never leave blank spaces in the medical record. The nurse should draw a line through any blank spaces and sign her name at the end to prevent others from adding information to the entry. 44. The nurse is completing a change-of-shift report. Which statement wouldn't be appropriate for a nurse to include in the report?
A. The client was admitted with a diagnosis of myocardial infarction. B. The client lives at home with his wife and two children. C. The client had chest pain relieved with one sublingual nitroglycerin tablet. D. The client is scheduled for a cardiac catheterization in the morning and will be nothing by mouth after midnight. RATIONALE: Biographical data provided in the client's Kardex or care plan shouldn't be repeated in a change-of-shift report. The shift report should include essential information, such as the client's name, sex, age, changes in the client's condition, treatments, and the client's response to treatment. Other significant information, such as scheduled tests and preparations, may be included. 45. A 19-year-old male client is diagnosed with prostate cancer. Which nursing action constitutes an invasion of the client's privacy? A. Covering the client with a blanket before transporting him through the hospital corridors B. Pulling a curtain around the bed before performing a prostate examination C. Refusing to discuss the details of the young man's condition with coworkers in an elevator filled with staff D. Telling the family that the client has cancer without the client's knowledge RATIONALE: Providing information to an adult client's family without the client's knowledge or permission is an invasion of the client's privacy. Walang lugar sa ospital ang intrimitida and atribidang nurse. The other options, properly covering a client before moving him through hospital corridors, shielding a client during personal care, refusing to discuss client information with people who don't have a need to know , all demonstrate appropriate respect for the client's privacy. 46. The parents of a 4-year-old with sickle cell anemia tell the nurse that they would like to have other children, but they're concerned about passing sickle cell anemia on to them. Which health care team member would be the most appropriate person for the nurse to refer them to? A. B. C. D.
Clergy Social worker Certified nurse midwife Genetic counselor
RATIONALE: A genetic counselor can educate the couple about an inherited disorder, screening tests that can be done, and treatments and can provide emotional support. Clergy are available to provide spiritual support. A social worker can provide emotional support and help with referrals for financial problems. A nurse midwife cares for women during pregnancy and birth. 47. The family of a child dying from leukemia asks the nurse about organ donation. Who must give consent for the child's organs to be donated? A. B. C. D.
Member of the clergy Physician Parents Court-appointed surrogate, as designated under the Uniform Anatomical Gift Act
RATIONALE: A parent or legal guardian may give permission for organ donation. A member of the clergy can't give permission for organ donation; however, a family member may seek the clergy's guidance in making this decision. The physician may only ask the family to consider organ donation. The Uniform Anatomical Gift Act provides clients and family members with the right to choose organ donation, but doesn't allow for designation of a surrogate to make decisions related to organ donation. 48. Parents whose first child has celiac disease ask the nurse if all of their children will have the disease. To whom should the nurse refer them? A. B. C. D.
Registered dietitian Genetic counselor Certified nurse midwife Social worker
RATIONALE: Celiac disease is believed to be a dominantly inherited, inborn error of metabolism. A genetic counselor could explain about inherited disorders, how they're inherited and, when appropriate, provide screening tests. A registered dietitian could provide in-depth education about a gluten-free diet and help the family adapt the diet to their special needs. A social worker could provide the family with emotional support and help with referrals for financial problems. A nurse midwife cares for women during pregnancy and childbirth. 49. The nurse is caring for a school-age child with cerebral palsy. The child has difficulty eating using regular utensils and requires a lot of assistance. Which of the following referrals is most appropriate? A. B. C. D.
Registered dietitian Physical therapist Occupational therapist Nurse's aide
RATIONALE: An occupational therapist helps physically disabled clients adapt to physical limitations and is most qualified to help a child with cerebral palsy eat and perform other activities of daily living. A registered dietitian manages and plans for the nutritional needs of children with cerebral palsy, but isn't trained in modifying or fitting utensils with assistive devices. A physical therapist is trained to help a child with cerebral palsy gain function and prevent further disability but not to assist the child in performing activities of daily living. A nurse's aide can help a child eat; however, the nurse's aide isn't trained in modifying utensils. 50. An 18-year-old pregnant woman tells the nurse that she's concerned that she may not be able to take care of herself during her pregnancy. She states that prenatal care is expensive and her job doesn't provide insurance. The nurse should recognize that she: A. B. C. D.
may not take care of herself. may not be fit to take care of a child. needs to take up a second job. should be referred to community resources available for pregnant women.
RATIONALE: The client needs to know that resources are available to her, and the nurse should help her to find those resources. Health care can be costly, but it doesn't necessarily mean that the client has no interest in caring for herself or her child. Taking up a second job doesn't necessarily rectify this situation.
51.The nurse is caring for a client with hyperemesis gravidarum who will need close monitoring at home. When should the nurse begin discharge planning? A. B. C. D.
On the day of discharge When the client expresses readiness to learn When the client's vomiting has stopped On admission to the hospital
RATIONALE: Discharge planning should begin when a client is first admitted to the hospital. Initially, discharge planning requires collecting information about the client's home environment, support systems, functional abilities, and finances. This information is used to determine what support services will be needed. Notifying support services on the day of discharge won't be sufficient to ensure meeting the client's needs in a timely fashion. Waiting until the day of discharge to begin planning is also likely to cause the client to become overwhelmed and anxious. Factors such as when the client stops vomiting or expresses readiness to learn shouldn't influence when the nurse begins discharge planning. 52. The parents of a 5-year-old call the clinic to tell the nurse that they think their child has been abused by her day-care provider. What should the nurse advise them to do? A. Take the child to the emergency department of the local hospital. B. Schedule an immediate appointment with their health care provider. C. Call the child protective services to file a complaint. D. Talk to their attorney to file charges against the accused. RATIONALE: Because more information needs to be obtained from the child and family, an immediate appointment is most appropriate. It's unclear what type of abuse the parents are concerned about. Taking the child to the emergency department would be appropriate if the child had been sexually abused within the past few hours or if the child needed immediate treatment for trauma. Calling child protective services is appropriate but isn't the first action to take; neither is talking to an attorney. 53. The nurse is concerned about another nurse's relationship with the members of a family and their ill preschooler. Which of the following behaviors would be most worrisome and should be brought to the attention of the nurse-manager? A. The nurse keeps communication channels open among herself, the family, physicians, and other health care providers. B. The nurse attempts to influence the family's decisions by presenting her own thoughts and opinions. C. The nurse works with the family members to find ways to decrease their dependence on health care providers. D. The nurse has developed teaching skills to instruct the family members so they can accomplish tasks independently. RATIONALE: When a nurse attempts to influence a family's decision with her own opinions and values, the situation becomes one of overinvolvement on the nurse's part and a nontherapeutic relationship. Bawal talaga an glider-lideran and nagmamarunong na nurse. When a nurse keeps communication channels open, works with family members to decrease their dependence on health care providers, and instructs family members so they can accomplish tasks independently, she has developed an appropriate therapeutic relationship.
54. When meeting with parents who will learn that their 3-yearold is seriously ill, which action demonstrates the nurse's role as collaborator of care? A. Provide the parents with information about financial assistance programs. B. Inform the family of the diagnosis and recently discovered findings. C. Coordinate the multidisciplinary services and provide information about them. D. Refer and consult with other specialties to help in treating the diagnosis. RATIONALE: The nurse can coordinate care when multiple services are involved, explaining the function of each service (social services, case management, counseling services, and so forth). For instance, providing parents with information about financial assistance programs is the responsibility of social services. Informing the family of the diagnosis and recently discovered findings is a physician's responsibility, as are referring and consulting with other specialties. CBQ ito. 55. In planning a presentation that advocates a decrease in the client-to-nurse ratio from 8:1 to 6:1, a nurse should emphasize its effect on: A. B. C. D.
institutional resources. standards of practice. client-care quality. nursing recruitment.
RATIONALE: Client-care quality should always be the first consideration when proposing a change in care provision. Institutional resources, standards of practice, and nursing recruitment will all influence the decision but none as much as client-care quality should. 56. The employer of a client on the psychiatric unit calls the nursing station inquiring about the client's progress. The nurse doesn't know if the client has given consent to allow the staff to give information out to callers on the phone. Which of the following would be the nurse's best response? A. B. C. D.
"I'm not permitted to discuss her progress." "I'll give you the name and telephone number of her physician." "I'll have her call you." "I can't confirm whether your employee is a client here."
RATIONALE: The nurse's release of information to the client's employer without the client's consent is a breach of confidentiality. The stigma associated with psychiatric illness may affect the client's employment; therefore, it's better to maintain confidentiality and refrain from disclosing any information about the client, including whether she's a client in the hospital. As a patient advocate, we must always protect the privacy of our patient except on situations of national security, eg. Politician or prominent figure ung tao. Nagrerelease ng medical bulletin pag ganun but it’s usually the hospital director or the physician who does that and hindi ang nurse. 57.Based on multiple referrals, the nurse determines that childhood injuries are increasing in the community in which she practices. The first step the nurse would take in developing an educational program is:
A. assessing for a decrease in referrals following a pediatric safety class. B. assessing the strengths and needs of the community while identifying barriers to learning. C. choosing a health promotion or health belief model as a framework. D. developing and implementing a specific plan to decrease childhood injuries. RATIONALE: Following the identification of a learning need, the first step is to assess the strengths and needs of the community while identifying barriers to learning. Pancinin, kapag community setting, kapag you really really don’t know the answer, madalas it’s the longest statement. 58. A registered nurse who usually works on a medical-surgical unit is told to report to the cardiac care unit (CCU) for the day because the CCU is short staffed and needs additional help to care for the clients. The nurse has never worked in the CCU. Which of the following responses is the most appropriate nursing action? A. Call the hospital lawyer. B. Report to the CCU and identify tasks that she feels she can safely perform. C. Speak to the nursing supervisor. D. Refuse to go to the CCU. RATIONALE: When the nurse is placed in this situation, the most appropriate action is to set priorities and identify potential areas of harm to the client. Reassignment to another nursing area is an acceptable legal practice used by hospitals to meet their staffing needs. A nurse can't legally refuse to be reassigned unless there's a specific clause in her union contract. Safety is always a priority! 59. A nurse-manager is explaining the unit's performance improvement (PI) program to a newly hired nurse. Which of the following should she include as one of the primary purposes of the PI program? A. B. C. D.
Evaluation of client outcomes Evaluation of staff member performance Improvement in the efficiency of care Preparation for accreditation
RATIONALE: PI programs ensure that the best care is delivered to clients. This can be measured by evaluating client outcomes. Staff performance evaluations focus on staff, not client outcomes. Improvement in the efficiency of care may be an aspect of quality care but it isn't the goal. Although PI is one component required for accreditation, the goal is to ensure that the best care is delivered, not to ensure accreditation. 60. Two family members are arguing in a child's room. They start to hit each other and the child is crying. What's the most appropriate nursing action? A. B. C. D.
Call security to come and intervene. Remove the child from the room. Ask one of the family members to leave the room. Try to reason with both family members.
RATIONALE: The first action would be to protect the child by removing him from the room. Calling security is necessary but only after ensuring the safety of the child. Asking one of the family members to leave the room or reasoning with them
would be ineffective at this point and may even escalate the situation. Wag makialam sa mga away ng family members ng patient ok. 61. The nursing supervisor is called to the emergency department to assist with a 10-month-old infant with injuries consistent with child abuse. The nursing supervisor confers with the emergency department physician. To whom must she report the incident? A. B. C. D.
A social worker The medical director of the emergency department A Children's Protective Services (CPS) representative A public health nurse
RATIONALE: Suspected child abuse must be reported to a CPS representative. Sa Pilipinas, bantay Bata or DSWD. Reporting a potential abuse doesn't indicate guilt, only suspicion or risk. The CPS and the judicial system will follow the correct legal process to establish the need for prosecution and counseling. 62. The nurse-manager has noticed a sharp increase in the mediation errors with I.V. antibiotics over the last month. She discusses the situation with each nurse involved. What other action should she take? A. Document it on their evaluation. B. Ask them to attend inservice training for administration of I.V. medications. C. Report them to the supervisor. D. Report the incidents to the hospital attorney. RATIONALE: Identification of causes of medication errors requires inservice education to inform the staff of strategies to decrease these errors. Errors are frequently the result of systemic problems that can be identified and rectified through problem-solving techniques and changes in procedures. Documenting or reporting the situation wouldn't directly assist the nurses in eliminating errors. Reporting the incidents to the hospital attorney isn't necessary. 63. When reporting to the surgeon that a chest tube is malfunctioning, the nurse is ordered to reposition the tube and obtain a chest radiograph. The nurse should: A. B. C. D.
inform the surgeon this isn't within her scope of practice. report the surgeon to the Ethics Committee. report the surgeon to the nursing supervisor. follow the order as requested by the surgeon.
RATIONALE: Initially, the nurse needs to inform the surgeon that the task is outside the scope of nursing practice. Bawal ang atribida nad nagmamarunong na nurse kea, If the surgeon still requests the activity, the nurse should refuse to perform the task and should follow the chain of communication for reporting unsafe practice according to the hospital's policy. The nurse must not comply with any order that goes beyond the scope of nursing practice. 64. An Iranian mother and father admit their 14-month-old son to the pediatric unit for treatment of leukemia. When the female pediatric oncologist, who isn't Muslim, introduces herself, they became uncooperative and refused treatment. The nurse should be aware that this change of behavior is probably related to: A. the gender of the physician.
B. fear of being accused of child abuse and neglect by an authority figure. C. religious barriers that prevent the family from accepting care from someone who isn't of their religion. D. aggressiveness of Middle Easterners. RATIONALE: The Iranian tradition of male authority is still strong. Accepting a woman making life-and-death decisions for their son may be very difficult for these parents. Discussing with the parents other options, such as the idea of turning the case over to a male Muslim oncologist, would be appropriate. The gender issue is a stronger cultural factor than the religious difference. There's no basis to relate the parents' behavior to fear of being charged with abuse or neglect. Attributing the behavior to Middle Eastern aggressiveness reflects a stereotype, not a culture value. 65. Which of the following clients would be a priority for the nurse to evaluate when assuming responsibility for their care at the beginning of the day shift? A. The client who had a total laryngectomy the previous day B. The client with diabetes who had a fasting blood glucose of 150 mg/dl C. An elderly client who has Alzheimer's disease and periods of confusion D. A client with a pneumothorax who had a chest tube inserted earlier in the day RATIONALE: Based on the information provided, the client who is on day 1 after a total laryngectomy would be the priority client for the nurse to evaluate. This client is at risk for impaired respiratory status and should be monitored closely coz edematous ang neck area nya and baka magkaron ng airway obstruction. Clients with acute conditions that can affect their respiratory status are a high priority for nursing care.
End of PROFESSIONAL ADJUSTMENT AND NURSING CARE MANAGEMENT PRACTICE EXAM
