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Southern University: HIMS 112/PN Management Online Practice 2017 A,100% CORRECT

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Southern University: HIMS 112/PN Management Online Practice 2017 A A nurse in an outpatient clinic is caring for a client who has schizophrenia. For which of the following client actions should the nurse recommend transfer to an acute care facility? The client develops command hallucinations ...

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  • May 8, 2022
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  • 2021/2022
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Southern University: HIMS 112/PN Management Online
Practice 2017 A

A nurse in an outpatient clinic is caring for a client who has schizophrenia. For
which of the following client actions should the nurse recommend transfer to an
acute care facility?
The client develops command hallucinations
• Command hallucinations involve hearing "voices" that direct the
client to take specific actions. These actions can be directed at
causing self-harm or injury to others. To provide for safety of the
client and others, the nurse should recommend that the client be
transferred to an acute care facility.



A nurse is using a critical pathway while providing care to a client who is 3 days
postoperative. Which of the following events should the nurse document as a
variance?
The client has a circular area of nonblanchable redness on her left heel
• A variance occurs when expected outcomes of the critical pathway
are not met. The nurse should document that the client has a
circular area of nonblanchable redness on her left heel as a
variance because this indicates the initial stage of a pressure ulcer
and is not an expected outcome.


A nurse is preparing to reinforce discharge teaching with a client who does not
speak the same language as the nurse. Which of the following actions should the
nurse plan to take?
• Select an interpreter who is the same gender as the client.

Ensure interpreters provided by the facility have knowledge of medical

terminology. Choose an interpreter from the same ethnic background

as the client.

,A charge nurse is asked by two staff nurses to assist in resolving a conflict about
holiday scheduling. Which of the following actions should the charge nurse take?
Encourage each staff nurse to give up something as part of the negotiation.
• The charge nurse should encourage each staff nurse to give up
something as part of the negotiation so that a compromise can be
reached that is a win-win situation for each party.



A nurse overhears two assistive personnel discussing the details of a clients
diagnosis and treatment plan int the hospital cafeteria. Which of the following
actions should the nurse take?
Inform the APs that the conversation violates the client’s confidentiality

, • The nurse should intervene immediately to stop the conversation
and protect the client by informing the APs that the conversation
violates the client's confidentiality.



A nurse in a skilled nursing facility is caring for a group of clients. Which of the
following actions demonstrates the nurses role as client advocate?
• The nurse assists a client in communication end of life decisions to the
provider
The nurse acts in the role of client advocate when protecting the client's
legal and ethical rights.



A nurse is preparing to document client care in the electronic health record for a
client who is postoperative. Which of the following should the nurse include in the
documentation?
• A treatment that was refused by the client.
The nurse should document treatments that were omitted due to client
refusal in the medical record.



A home health nurse is reinforcing teaching about the effects of carbon
monoxide poisoning. Which of the following manifestations should the nurse
include?
• Headaches
The nurse should reinforce in the teaching that headaches, dizziness,
nausea, vomiting, loss of muscle control, and muscle weakness are
manifestations of carbon monoxide poisoning.



A nurse in a long-term care facility enters a client's room and finds the client lying
on the floor. Which of the following actions should the nurse take first?
• Check the client for injuries.
When using the nursing process, the nurse should identify that the priority
action is to collect data from the client. Therefore, the first action the nurse

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