Question 1

A visiting family member of a hospitalized client reports sudden onset of a headache and numbness in half of the body. The visitor asks the nurse to take a blood pressure reading. What is the most appropriate response by the nurse?

Accepted Answer

Providing care establishes a legal caregiver obligation/relationship between the nurse and the visitor. If a relationship is started, the nurse has a duty to continue care until the visitor is stable or other health care personnel can take over. If proper care is not continued, the nurse could be accused of negligence (ie, failure to act in a prudent manner as would a nurse with similar education/experience). This visitor's symptoms are potentially serious as sudden onset of headache and numbness in half of the body may indicate stroke. In the event of a visitor emergency, the nurse should not establish a caregiver relationship but rather implement facility protocol to help the visitor get to the emergency department promptly to receive immediate assessment and further evaluation (Option B). (Options A and D) Asking the visitor to call the health care provider (HCP) or giving advice to lie down delays the essential assessment and treatment that this visitor with potentially serious symptoms requires. (Option C) When a nurse provides care (eg, takes blood pressure), a client-caregiver relationship is established. The nurse caring for a visitor is ill-equipped to provide care without any HCP prescriptions in place and risks being negligent. Educational objective: Providing care establishes a legal caregiver obligation/relationship between the nurse and a visitor. In the event of a visitor emergency, the nurse should refrain from actions that establish this relationship and instead implement facility protocol to help get the visitor promptly to the emergency department.

Question 2

The nurse is participating in staff training about protecting clients' privacy and confidentiality. Which of the following incidents does the nurse recognize as a violation of client confidentiality? Select all that apply.

Accepted Answer

The nurse is ethically and legally obligated to protect clients' privacy and maintain confidentiality of their medical information. Clients' health information should be shared only with other health care team members directly involved in those clients' care. Report sheets used by nursing staff often include clients' private health information and must be shredded at the end of the shift (Option B). Without the client's permission, information about the diagnosis or diagnostic tests cannot be shared with a hospital roommate (Option C). (Option A) Health care staff are not required to censor visitor conversation in waiting rooms. (Option D) Nurses are obligated to help protect visitors and others by instructing visitors to wear appropriate personal protective equipment. However, the nurse should not violate the client's privacy by sharing the client's diagnosis. (Option E) Although discussion about specific client information is not permissible, general discussion about health care topics (eg, a potential cure for AIDS) is not a violation of clients' privacy. Educational objective: The nurse must protect clients' privacy and maintain the confidentiality of their medical information. Clients' health information should be discussed only with health care team members directly involved in those clients' care. Nurses must also ensure that documents containing clients' information are shredded after use.

Question 3

Which statements related to ethical nursing practices are correct? Select all that apply.

Accepted Answer

Ethical principles guide decision making and appropriate behavior. Justice is treating every client equally regardless of gender, sexual orientation, religion, ethnicity, disease, or social standing (Option D). Accountability refers to accepting responsibility for one's actions and admitting errors (Option A). Nonmaleficence means doing no harm. It also relates to protecting clients who are unable to protect themselves due to their physical or mental condition. Examples include infants/children, clients under the effects of anesthesia, and clients with dementia (Option E). (Option B) Autonomy is freedom for a competent client to make decisions for oneself, even if the nurse or family does not agree (eg, informed consent, advanced directive). The nurse can provide information and should respect the client's decisions. (Option C) Confidentiality means that information shared with the nurse is kept in confidence unless permission is given to share or it is required by law to be shared to protect the client and/or community (eg, reportable infectious diseases). If a client discusses suicidal ideation with the nurse, it must be appropriately reported to protect the client from self-harm. Educational objective: Accountability is accepting responsibility for one's actions. Autonomy is making an informed decision about treatment for oneself. Confidentiality is not sharing information unless permission is given or required by law. Justice is treating every client equally. Nonmaleficence is doing no harm.

Question 4

A housekeeping employee tells the staff nurse of having a headache and asks for acetaminophen.  How should the nurse respond?

Accepted Answer

Although acetaminophen is an over-the-counter drug, the nurse should not give it without a prescription. By doing so, the nurse would be functioning outside the job description. There has not been a proper assessment (eg, allergies, liver disease), and a legal caregiving relationship will be established by administering the medication. If the employee does not want to go to the employee health provider, the nurse can suggest that the employee purchase acetaminophen in the gift shop. (Option A) It is advisable for the nurse to ask about liver issues prior to administering acetaminophen, but this nurse has no prescription to administer it. Taking the medication from a personal supply, rather than hospital stock, does not change the fact that the nurse is functioning outside the job description while on duty. (Option B) The nurse could technically perform the assessment, but it is not within the nurse's current role and job description. The employee health provider (or the emergency department) should be used for this assessment. (Option C) The nurse should check for allergies before administering a drug, but this nurse has no prescription to administer acetaminophen. Acetaminophen being an over-the-counter medication does not change this fact. Educational objective: The nurse should not give medication to an employee without a prescription even if it is an over-the-counter drug.

Question 5

A newly reassigned nurse enters a hospital room at the beginning of the shift and finds the client unconscious and unresponsive.  Resuscitation is initiated and then continued by the rapid response team.  The nurse realizes that there is a do not resuscitate (DNR) prescription posted in the client's chart.  Which action is correct?

Accepted Answer

Many health care professionals react to an emergency situation automatically. However, some states and provinces will further penalize health care workers with loss of their professional license if they fail to render cardiopulmonary resuscitation in an emergency situation. Health care professionals will not be penalized for an honest mistake. However, resuscitation must end immediately after they are notified of the error (Option A). (Option B) Continuing treatment until the code status is verified with the health care provider (HCP) constitutes malpractice. Before a do not resuscitate prescription can be posted in a client's medical record/chart, the HCP must provide documentation that the client's code status has been established through consultation with the client or family. (Options C and D) Gross negligence of a client's advance directive can result in legal action. Educational objective: Failure to stop an erroneous code on a client with an advance directive in a timely fashion may result in legal action.

Question 6

Which are correct understandings of applying nursing ethical principles? Select all that apply.

Accepted Answer

Ethical principles guide the nurse in making appropriate decisions and acting accordingly. They speak to the essence but not to the specifics of the law. Fidelity is exhibiting loyalty and fulfilling commitments made to oneself and others. It includes meeting the expected responsibilities of professional nursing practice and provides the basis of accountability (taking responsibility for one's actions) (Option C). Nonmaleficence means to do no harm and relates to protecting clients from danger when they are unable to do so themselves due to a mental/physical condition (eg, children, client with Alzheimer disease) and from a nurse who is impaired (Option E). (Option A) Autonomy is the right to make decisions for oneself (eg, informed consent). Although having an advance directive is an example of autonomy, requiring one violates this principle. The client has a right to refuse even if the nurse believes it is in the client's best interest. (Option B) When a diagnosis is withheld, even if due to the nurse's or family's good intentions, it violates the principle of autonomy. Beneficence means to do good (eg, implementing interventions to promote the client's well-being). (Option D) The principle of justice refers to treating all clients fairly (ie, without bias). Veracity is telling the truth as a fundamental part of building a trusting relationship. Educational objective: Nonmaleficence is doing no harm, fidelity is loyalty and commitment, justice is equal treatment for all, beneficence is doing good for the client's best interest, and autonomy is making decisions for oneself.

Question 7

The charge nurse in the emergency department assigns a client to a new nurse who has been off orientation for a week. Which client assignment is most appropriate?

Accepted Answer

A fractured clavicle (collarbone) is not uncommon in children age <10 years and is usually treated conservatively. A new nurse should be competent in performing the basic skills needed to care for a client with a musculoskeletal injury (eg, pain and neurovascular assessments, analgesia administration, sling application). The 8-year-old client, who has minimal pain as indicated by the score of 2 on the FACES pain assessment tool, is the most stable. As a result, this is the most appropriate assignment for the new nurse. (Option A) A seizure can be associated with a fever-related illness (febrile seizure). This client who is very irritable and has fever may have an underlying serious infection such as meningitis and should undergo diagnostic testing (eg, blood cultures, imaging, lumbar puncture). Therefore, this is not an appropriate assignment. (Option C) A peak flow meter measures airflow out of the lungs. The client who has a severely reduced peak expiratory flow rate (<50% of personal best) needs emergency intervention and is not an appropriate assignment. (Option D) The client with dyspnea and a maculopapular drug rash is most likely experiencing an antibiotic-related allergic reaction, which can range from mild to life-threatening anaphylaxis. This client is not an appropriate assignment. Educational objective: A new nurse should be competent in performing the basic skills needed to care for a client with a musculoskeletal injury (eg, pain and neurovascular assessments).

Question 8

Following a motor vehicle crash, the nurse stops to help a victim who has a laceration with spurting blood. The nurse giving reasonable assistance could be held liable despite Good Samaritan laws in which situations? Select all that apply.

Accepted Answer

Good Samaritan laws prevent civil action against nurses who stop of their own accord (eg, not part of their job duties) to help injured individuals after an accident. The nurse cannot receive payment for any care given (Option A). It is essential for the nurse to perform in the same manner as any reasonable and prudent medical professional would in the same or similar circumstances. A reasonable, prudent nurse would apply pressure to help control an arterial bleed (Option C). (Option B) Although this nurse is not legally obligated to offer assistance, it can be argued that there is an ethical responsibility. Once the nurse starts to render care, the nurse is responsible to continue until the care can be handed off to an appropriate caregiver, such as a paramedic. The nurse is not obligated to accompany the client to the hospital. (Option D) Knowing the client does not affect the application of Good Samaritan laws. (Option E) This nurse is not liable for the victim's outcome as long as the nurse performs in a competent manner. Educational objective: Good Samaritan laws prevent civil action if a nurse stops to assist after an accident, as long as the nurse acts competently, continues care until another appropriate caregiver takes over, and does not accept money.

Question 9

The nurse is eating lunch in the hospital cafeteria, which is crowded with visitors and other staff.  A health care provider approaches the nurse and asks, "How is my client Mrs. Jones in Room 312 doing?"  Which response by the nurse is appropriate?

Accepted Answer

The nurse is ethically and legally obligated to protect clients' privacy and maintain confidentiality of their medical information. If another staff member asks a question about a client's medical information in an open area with visitors, the nurse should first move the conversation to a secure area. Answering the question will promote further conversation, making it likely that the client's privileged health care information will be discussed and overheard by others. The best response is to suggest changing the location of the conversation so that the information can be discussed privately (Option B). (Option A) This response is neither accurate nor helpful because the nurse knows how the client was earlier in the day. It is best to make the conversation private so that the nurse can respond to the question appropriately. (Option C) Although vague, this response in a public area (ie, cafeteria) violates the client's privacy by acknowledging the client's presence in the hospital, where the response may be overheard by others. In addition, it does not provide accurate information. (Option D) It is appropriate to direct questions about the client to the currently assigned nurse; however, this response violates the client's privacy by confirming the client's presence in the hospital. It is best to make the conversation private before sharing any information. Educational objective: The nurse must protect clients' privacy and ensure that their medical information remains confidential. Conversations about the client with other staff, even those regarding the client's presence in the hospital, should occur in a private area.

Question 10

The charge nurse is making assignments for the oncoming shift. Which client assignments should be avoided by the nurse who is pregnant?

Accepted Answer

Parvovirus B-19 is a common childhood infection also known as "fifth disease." Infected clients display a characteristic "slapped cheek" rash on the face. Symptoms range in severity; however, most children do not require intervention. Transmission of the infection is usually through person-to-person contact, especially with respiratory secretions. Although rare, infection with parvovirus B-19 during pregnancy can cause fetal anomalies (eg, hydrops fetalis, stillbirth). It is recognized as a TORCH infection (Toxoplasmosis, Other [parvo-B19/varicella zoster], Rubella, Cytomegalovirus, Herpes simplex virus), a group of infections that cause fetal abnormalities. Delegation of this client to a pregnant nurse is inappropriate due to potential harm to the fetus. (Option A) A combative toddler should not be a hazard to the pregnant nurse. Appropriate precautions should be taken to ensure safety around combative clients. (Option B) Group A Streptococcus infection requires droplet precautions; however, it does not pose a perinatal infection risk. Group A Streptococcus may manifest as sore throat. (Option D) Extreme caution should be taken while handling cytotoxic medications; however, intrathecal administration days prior to contact should not pose a risk to the pregnant nurse. The nurse should use standard precautions if contact with the client's blood or bodily fluids is anticipated. Educational objective: Clients with infectious diseases that can be transmitted to the fetus (eg, TORCH infections) should not be assigned to a pregnant nurse. These infections, including parvovirus B19, can cause severe anomalies in the developing fetus.

Question 11

A client with terminal cancer arrives in the emergency department unresponsive and in respiratory distress.  The client's sister is the legal medical power of attorney.  Both the client's spouse and sister are present.  Which action by the nurse is appropriate at this time?

Accepted Answer

Advance directives are legal documents that allow clients to make decisions about their future medical treatment in case the client later becomes medically incompetent (eg, end of life, dementia, brain injury). The most common forms are living will and medical power of attorney (POA) (ie, health care surrogate/proxy). A living will declares the client's wishes related to specific situations (eg, do not intubate). A medical POA allows the client to designate a specific decision-making individual who can advocate for the client as needed and can be flexible in changing circumstances (Option B). (Option A) A client's spouse is typically the primary decision maker. However, clients have the right to declare any specific individual who they trust as their agent with medical POA, and the agent becomes the final decision maker. (Option C) The client should receive treatment immediately if there are no advance directives or family members present, but in this case, the agent authorized with medical POA is present and should approve the treatment plan before interventions are initiated. (Option D) If the client's medical POA agent is present, treatment should not be delayed by requesting a living will as the agent will advocate for the client's wishes and has final decision-making authority. Educational objective: Medical power of attorney (POA) is an advance directive that allows clients to designate a specific decision-making individual who advocates on their behalf if they become medically incompetent. Clients have the right to declare any individual they trust as their agent with medical POA, and that individual becomes the final decision maker.

Question 12

Which pediatric presentation in the emergency department should the nurse follow up for possible abuse and mandatory reporting?

Accepted Answer

11ecbb05_cb98_9e05_b433_492b563ab14b_MD0009_00 Infants do not start rolling until age 4 months and normally roll front to back at 5 months. This explanation for the injury does not fit the growth capacity of the child. Because lethargy is present, head injury must be ruled out. (Option B) Congenital dermal melanocytosis (Mongolian spots) are an expected finding. These are seen on the lower back and/or buttock more often in African American, Asian, Hispanic, and Native American infants. Although they can be mistaken for bruising and the size and location should be documented, they are not a concerning finding and usually disappear by school age. Congenital dermal melanocytosis (Option C) A toddler's forehead is the height of many tables. Due to toddlers' lack of coordination, this explanation is plausible in the absence of other concerning findings (eg, child is afraid of caregiver, multiple bruises of various ages over other parts of the body, malnourished). (Option D) Due to the child's short height, this is a credible explanation. A child can pull water down from a higher-level stove top. Burns that are suspicious for abuse include scalds without splash marks; scalds with a clear line of demarcation/immersion ("dunking"); scalds involving the perineum, genitalia, and buttocks; burns on the back (versus the front) of the child; mirror-image burn injury of the extremities; and cigarette burns. Educational objective: Infants begin to roll at age 4-5 months. History that does not match growth and development is a concern for abuse. Burns with splash, bruises from areas typically hit when falling, and Mongolian spots are expected findings.

Question 13

Which of the following are violations of protected client health information? Select all that apply.

Accepted Answer

Under the Health Insurance Portability and Accountability Act (HIPAA) and the Personal Information Protection and Electronic Documents Act (PIPEDA), a client's information regarding medical treatment is private and cannot be released without the client's permission. There must be a reasonable effort to limit the use of, disclosure of, and requests for protected health information (PHI) to the minimum necessary to accomplish the intended purpose. The client's PHI should not be shared with a partner or spouse without the client's permission (Option C). PHI is shared with an employee on a "need-to-know" basis. A transporting employee does not need to know the client's diagnosis, only information related to positioning/transferring or personal protective equipment (for infection precautions), if applicable (Option D). (Option A) A client overhearing report through a privacy curtain is inadvertent communication and is not considered a violation. (Option B) Calling a client by the first and last names in the waiting room is not a violation as long as no other pertinent information is given. (Option E) Any employee can provide socially acceptable well wishes to a client. This does not involve PHI. Educational objective: The Health Insurance Portability and Accountability Act and the Personal Information Protection and Electronic Documents Act requirements related to protected health information include not giving results to a spouse without permission or telling a client diagnosis to an employee who does not need to know it. It is not a violation to call clients by their names, have information overheard inadvertently, or indicate well wishes.

Question 14

Which emergency department clients cannot be allowed to sign out against medical advice? Select all that apply.

Accepted Answer

To leave against medical advice (AMA), the client must be legally competent to make an educated decision to stop treatment. Disqualifications for legal competency include altered consciousness, mental illness (ie, a danger to self or others), and being under chemical influence (eg, drugs or alcohol). The client who drank a 1 L bottle of vodka is intoxicated (Option B). The client who hears voices has psychotic symptoms and is potentially homicidal (Option C). The manic client who has not eaten in 5 days is a potential danger to self and cannot leave AMA (Option D). For a competent client to leave AMA, the health care provider must explain the risks of discontinuing treatment. The nurse must witness and document the discussion on risks of leaving AMA and the client's understanding of these risks ("informed refusal"). A client leaving AMA can, and should, receive discharge instructions and the option to return at any time. (Options A and E) Clients have the right to leave AMA, even if it is not in their best interests to leave (eg, even if potentially life-threatening). Not allowing a competent client to leave AMA is a form of false imprisonment, a legally liable action by the nurse. Educational objective: The client must be legally competent to leave against medical advice. Disqualifications for legal competency include impairment by drugs or alcohol, altered consciousness, and mental illness (ie, a danger to self or others).

Question 15

A male client has terminal metastatic disease.  He arrives at the emergency department with respirations of 6/min and an advance directive indicating to withhold resuscitative efforts.  What should the nurse's response be?

Accepted Answer

Advance directives are prepared by a client prior to the need to indicate the client's wishes. A living will gives instructions about future medical care and treatment if the client is unable to communicate. A medical power of attorney is the individual designated to make health care decisions should a client become unable to make an informed decision. It allows more flexibility to deal with unique situations. Because the client has indicated specific desires, these should be honored. This is especially true as the client has a terminal condition (versus, for example, an acute choking episode that could be easily reversed). Oxygen can provide comfort and is not resuscitative when given by nasal cannula. (Option B) Advance directives are determined ahead of time to guide decision making at the time of the event. The client can indicate a desire to make a change, and the original decision should be honored. This client could be experiencing hypoxia and thus not thinking as clearly as when the advance directives were made. Asking about changes could imply that he should make a change, which is not true. The original decision should be honored; however, the client can indicate a desire to make a change. (Option C) The client's advance directives take legal precedence over the spouse's wishes. The spouse is consulted when there are no advance directives or durable power of attorney for health care. (Option D) Advance directives include living wills with written directives on how to handle situations. A medical power of attorney is used in situations not covered by the written directives. This client has indicated his wishes. A durable power of attorney for health care is used only when clients have not expressed wishes or cannot speak for themselves. Educational objective: Advance directives include a living will (specific situations put in writing) or a medical power of attorney (an individual appointed when the clients are unable to speak for themselves). The client's wishes should be honored.

Question 16

Which situations would prompt the health care team to use the client's advance directive to make a decision regarding care? Select all that apply.

Accepted Answer

Advance directives give people the chance to make decisions about their medical treatment ahead of time in case they are unable to personally make their wishes known. The 2 most common forms are living wills and durable power of attorney for health care (health care surrogate/proxy). A client who is alert and oriented can directly address a health care decision. Clients in a coma (GCS score ≤7) or with expressive aphasia would need an advance directive to make treatment decisions because they cannot directly express their wishes. Aphasia involves the inability to express thoughts and comprehend language due to brain dysfunction and includes both verbalizing and writing (Options B and D). (Option A) Mental capacity is not affected in spinal cord compression. The client is able to speak. (Option C) An adult who is mentally capable of making decisions has the right to refuse treatment for any reason at any time whether the health care provider believes it is in the client's best interest or not. (Option E) A client who is oriented can make and communicate decisions for him/herself although unable to verbalize. The client could nod or write out wishes. Educational objective: Advance directives take effect when the client is unable to speak for him/herself due to such conditions as mental incapacity. Aphasia involves the inability to express thoughts and comprehend language due to brain dysfunction and includes both verbalizing and writing.

Question 17

A client with end-stage renal disease, oxygen-dependent chronic obstructive pulmonary disease (COPD), and a Do Not Resuscitate (DNR) code status is admitted to the medical floor for COPD exacerbation. The nurse walks into the room and finds that the client is not breathing. What should the nurse do first?

Accepted Answer

The nurse has a medical order stating that the client should not be resuscitated. Therefore, the appropriate first action is to assess the apical pulse. Then the nurse should call the HCP. If the client's family members are present, the nurse should explain what is happening and make sure that they have support. (Option A) Activating the code system is not appropriate as this client has an order to withhold resuscitation. (Option B) The nurse should assess the client and then call the HCP. A stat page is not needed when the client is DNR. (Option D) Measuring the blood pressure is not appropriate if this client has stopped breathing. Checking an apical or central pulse would be appropriate after noticing that the client is not breathing. Educational objective: A DNR order requires the nurse to withhold resuscitation in the event of a cardiac or respiratory arrest. If an event occurs, the nurse should assess for breathing and check the central or apical pulse. After performing these actions, the nurse should call the HCP to confirm the death.

Question 18

A client with metastatic esophageal cancer says, "I don't want to be kept alive being fed by a tube." What are the most appropriate ways for the nurse to ensure that this information is available to all who may need it for future decision-making? Select all that apply.

Accepted Answer

Advance care planning is a process that includes: Considering treatments that may be needed in the future Making decisions to guide future treatments, particularly if the client is no longer able to make own decisions Ensuring that treatment decisions are legally documented on the appropriate forms, such as the advance directive, and in the medical record (Option A) Ensuring that advance directive documents are in the medical record so that they are available to HCPs who care for the client in the future (Option C) Ensuring that the health care proxy (or durable power of attorney for health care) has information and documentation to support that role if this person needs to make decisions for the client (Option B) The nurse's role as advocate includes discussing options with the client and ensuring that the client's wishes are communicated and documented appropriately so that the health care proxy and health care team will have the necessary information. (Option D) An informed consent is necessary for the client or surrogate decision maker to approve certain treatments, procedures, and surgeries. The nurse's role in obtaining informed consent is to obtain and witness a signature once the HCP has explained the procedure, its risks and benefits, and answered any questions. This client is not providing consent for any procedure at this time. (Option E) A DNR order is used to prevent resuscitation in someone with a life-limiting illness. A DNR order does not provide direction for nutrition supplementation. Educational objective: An advance directive is used to communicate a client's wishes when the client is not able to communicate them him/herself. The nurse can advocate for the client by ensuring that expressed wishes are communicated in the advance directive and medical record and by encouraging the client to share this information with the appointed health care proxy.

Question 19

An elderly client visits the clinic for an annual examination, which includes updating the client's advance care plan. When assessing the client's advance care planning needs, which topics should the nurse discuss? Select all that apply.

Accepted Answer

Advance care planning is an ongoing process that should be revisited yearly and after changes in condition. Legal documentation is needed to ensure that the client's advance care plan is carried out correctly. Advance care planning documents may include the following: A health care proxy (durable power of attorney for health care or medical power of attorney) is a person appointed by the client to make decisions on behalf of the client. The proxy document only goes into effect when the health care team determines that the client lacks the capacity to make decisions. This should be deactivated if the client regains decision-making capacity. A living will is an advanced directive describing the type of life-sustaining treatments (eg, cardiopulmonary resuscitation, intubation, mechanical ventilation, feeding tube) that the client wants initiated if unable to make decisions. (Option A) The financial power of attorney form can help clients having difficulty managing financial affairs and needing someone to help; however, it is not part of the advance care planning process. (Option C) The client must choose a beneficiary for life insurance policies; however, life insurance is not part of the advance care plan. (Option E) A safe deposit box can be a good place to ensure that legal documents are stored safely. It is not part of the advance care planning process. Educational objective: Advance care planning allows the client to determine desired treatments (eg, cardiopulmonary resuscitation, intubation, mechanical ventilation) and decision makers in the event the client is unable to do so. Advanced directives are legal documents outlining these wishes and include living wills and health care proxies (durable powers of attorney for health care or medical power or attorney).

Question 20

Which emergency department client would be allowed to leave against medical advice after the risks are discussed with the primary health care provider?

Accepted Answer

To leave against medical advice (AMA), a client must have the risks explained and be able to understand them (ie, competent). Issues that can make a client ineligible to leave AMA include danger to self or others, lack of consciousness, altered consciousness, mental illness, being under chemical influence, or a court decision. Despite it not being in the client's best health interest, the client with gastrointestinal bleeding can leave AMA (Option D). (Option A) Parents may not refuse life-, limb-, or organ-saving treatment on behalf of their minor child for religious or personal reasons; they can make that decision only for themselves. If the parents deny critical treatments to the child, the hospital may seek protective custody. (Option B) Suicidal ideation (ie, danger to self) is a criterion that prevents a client from being allowed to leave AMA. (Option C) The client is not oriented x3 and is therefore not competent. There are 3 orientation categories (time, place, and person); orientation to time is lost first. To be oriented, the client must answer all questions in each category correctly. Educational objective: After an explanation of the risks is given, a client must be considered competent in order to leave against medical advice. A client with suicidal ideation or altered consciousness is not competent. Parents may not refuse limb-, life-, or organ-saving treatment for a minor child based on their own personal beliefs.

Exam 5: Leadership & Management

A visiting family member of a hospitalized client reports sudden onset of a headache and numbness in half of the body. The visitor asks the nurse to take a blood pressure reading. What is the most appropriate response by the nurse?

The nurse is participating in staff training about protecting clients' privacy and confidentiality. Which of the following incidents does the nurse recognize as a violation of client confidentiality? Select all that apply.

Which statements related to ethical nursing practices are correct? Select all that apply.

A housekeeping employee tells the staff nurse of having a headache and asks for acetaminophen. How should the nurse respond?

Which are correct understandings of applying nursing ethical principles? Select all that apply.

The charge nurse in the emergency department assigns a client to a new nurse who has been off orientation for a week. Which client assignment is most appropriate?

Following a motor vehicle crash, the nurse stops to help a victim who has a laceration with spurting blood. The nurse giving reasonable assistance could be held liable despite Good Samaritan laws in which situations? Select all that apply.

The nurse is eating lunch in the hospital cafeteria, which is crowded with visitors and other staff. A health care provider approaches the nurse and asks, "How is my client Mrs. Jones in Room 312 doing?" Which response by the nurse is appropriate?

The charge nurse is making assignments for the oncoming shift. Which client assignments should be avoided by the nurse who is pregnant?

A client with terminal cancer arrives in the emergency department unresponsive and in respiratory distress. The client's sister is the legal medical power of attorney. Both the client's spouse and sister are present. Which action by the nurse is appropriate at this time?

Which pediatric presentation in the emergency department should the nurse follow up for possible abuse and mandatory reporting?

Which of the following are violations of protected client health information? Select all that apply.

Which emergency department clients cannot be allowed to sign out against medical advice? Select all that apply.

A male client has terminal metastatic disease. He arrives at the emergency department with respirations of 6/min and an advance directive indicating to withhold resuscitative efforts. What should the nurse's response be?

Which situations would prompt the health care team to use the client's advance directive to make a decision regarding care? Select all that apply.

A client with metastatic esophageal cancer says, "I don't want to be kept alive being fed by a tube." What are the most appropriate ways for the nurse to ensure that this information is available to all who may need it for future decision-making? Select all that apply.

An elderly client visits the clinic for an annual examination, which includes updating the client's advance care plan. When assessing the client's advance care planning needs, which topics should the nurse discuss? Select all that apply.

Which emergency department client would be allowed to leave against medical advice after the risks are discussed with the primary health care provider?