Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
A nurse is caring for a newly admited older adult client.
Nurses' Notes
Day 1, 12:00:
Transferred to medical-surgical unit from emergency department (ED) for continued care following a closed reduction and immobilization of a fracture of the right arm. Accompanied by adult child.
Client in visibly soiled night clothes with multiple stains, including what appears to be dried blood. Hair, teeth, and fingernails unclean. Strong body odor noted. Bruising of various stages noted around upper arms, back, shoulders, and neck area.
Client is soft-spoken, speaks almost in a whisper, does not make eye contact with nurse.
Client looks at their child before answering the nurse's questions and, when asked how the injury occurred, mumbles "I don't know. Ask them." Client's child states, "He gets confused sometimes. I can answer your questions."
Which of the following interventions should the nurse recommend to include in the client's plan of care?
Select all that apply.
A. Tell the client's child that they will be reported for maltreatment of the client.
It is not appropriate for the nurse to threaten the client's child with reporting for maltreatment without further assessment and evidence.
B. Ask the client's child to provide details regarding the client's fractured arm.
Will provide additional information about the client's injury and help the nurse assess the potential for abuse or neglect.
C. Discuss respite care options with the client's child.
May help alleviate any caregiver stress or burden, and ensure the client's continued care and safety.
D. Speak to the client privately.
Will help establish trust and rapport, and allow the client to disclose any concerns or issues that they may not feel comfortable sharing in front of their child.
E. Provide legal advice to the client regarding power of atorney.
Is not within the scope of nursing practice and should be referred to a legal professional. Additionally, the client's capacity to make decisions and appoint a power of atorney should be assessed before providing such advice.
This question is an excerpt from Nurse Dive's nursing test bank - PN Comprehensive Predictor PN 2020 Proctored Exam. Take the full exam now
Full Explanation
The correct answers are b, c, and d.
a. It is not appropriate for the nurse to threaten the client's child with reporting for maltreatment without
further assessment and evidence.
b. Asking the client's child to provide details regarding the client's fractured arm will provide additional information about the client's injury and help the nurse assess the potential for abuse or neglect.
c. Discussing respite care options with the client's child may help alleviate any caregiver stress or burden, and ensure the client's continued care and safety.
d. Speaking to the client privately will help establish trust and rapport, and allow the client to disclose any concerns or issues that they may not feel comfortable sharing in front of their child.
e. Providing legal advice regarding power of atorney is not within the scope of nursing practice and should be referred to a legal professional. Additionally, the client's capacity to make decisions and appoint a power of atorney should be assessed before providing such advice.
Similar Questions
A nurse is administering a client's morning oral medications.
Which of the following actions should the nurse take?
A. Verify the medication three times with the medication administration record.
When administering oral medications, the nurse should verify the medication three times with the medication administration record to ensure that the correct medication is being given to the correct client at the correct time. This is known as the "three checks" and is an important step in preventing medication errors.
B. Document medication administration prior to administering medication.
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C. Administer time-critical medication 60 min before or after the scheduled time.
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D. Identify the client by using one identifier before giving the medication.
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Full Explanation
a. Verify the medication three times with the medication administration record.
When administering oral medications, the nurse should verify the medication three times with the medication administration record to ensure that the correct medication is being given to the correct client at the correct time. This is known as the "three checks" and is an important step in preventing medication errors.
A nurse is preparing to administer eye drops to a child.
Which of the following actions should the nurse take?
A. Apply pressure to the lacrimal punctum after administering the drops.
When administering eye drops to a child, the nurse should apply gentle pressure to the lacrimal punctum (the small opening in the inner corner of the eye) after administering the drops. This can help prevent the medication from draining into the tear duct and being absorbed into the bloodstream, which can reduce systemic side effects.
B. Position the child side-lying on the bed before administering the drops.
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C. Wipe from the outer to the inner canthus after administering the drops.
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D. Flush the eye with normal saline solution before administering the drops.
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Full Explanation
a. Apply pressure to the lacrimal punctum after administering the drops.
When administering eye drops to a child, the nurse should apply gentle pressure to the lacrimal punctum (the small opening in the inner corner of the eye) after administering the drops. This can help prevent the medication from draining into the tear duct and being absorbed into the bloodstream, which can reduce systemic side effects.
A nurse in an acute care setting is assisting in collecting client information to include in a referral for a physical therapist.
Which of the following information should the nurse plan to include?
A. Family medical history
Family medical history may be important for overall client care, but isnot directly relevant to a referral for a physical therapist.
B. Medications taken prior to admission
Medications taken prior to admission may be relevant if they affect the client's physical abilities or pain level, but again, physical assessment findings are more directly related to the referral for a physical therapist.
C. Physical assessment findings
Are important to include in a referral for a physical therapist because they provide information about the client's current physical condition, including range of motion, strength, and any areas of pain or discomfort. This information is essential for the physical therapist to develop an appropriate treatment plan for the client.
D. Medical health insurance claims
Medical health insurance claims may be important for overall client care, but isnot directly relevant to a referral for a physical therapist.
Full Explanation
c. Physical assessment findings
Physical assessment findings are important to include in a referral for a physical therapist because they provide information about the client's current physical condition, including range of motion, strength, and any areas of pain or discomfort.
This information is essential for the physical therapist to develop an appropriate treatment plan for the client. Family medical history and medical health insurance claims may be important for overall client care, but are not directly relevant to a referral for a physical therapist.
Medications taken prior to admission may be relevant if they affect the client's physical abilities or pain level, but again, physical assessment findings are more directly related to the referral for a physical therapist.