A nurse is educating staff members on the laws governing voluntary admissions. Which of the following statements by a staff member indicates an understanding of the teaching?

"If a client is gravely disabled, they may request admission as a voluntary individual."

"If a client under voluntary admission requests to leave, the nurse should contact the provider."

"Clients are not required to complete an admission application for voluntary admission."

"Clients under the age of 16 require involuntary commitment rather than voluntary admission."

Answer and Explanation

The Correct Answer is B

A. "If a client is gravely disabled, they may request admission as a voluntary individual.": Clients who are gravely disabled typically cannot make informed decisions regarding their care, so they would not be eligible for voluntary admission. Voluntary admission requires the client to have the capacity to consent to treatment.

B. "If a client under voluntary admission requests to leave, the nurse should contact the provider.": Clients admitted voluntarily have the right to request discharge, but the nurse must notify the healthcare provider to ensure safe discharge planning and evaluate if any legal or medical concerns exist. This statement reflects correct understanding of the legal responsibilities in voluntary admissions.

C. "Clients are not required to complete an admission application for voluntary admission.": Voluntary admission generally requires completion of an admission application or consent form to document the client’s agreement to treatment. Omitting this step would not comply with legal or institutional requirements.

D. "Clients under the age of 16 require involuntary commitment rather than voluntary admission.": Minors can be admitted voluntarily with parental or guardian consent depending on state law. They do not automatically require involuntary commitment, so this statement reflects a misunderstanding of the regulations surrounding voluntary admission of minors.

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Free Nursing Study Resources

Correct Answer is ["A","B","C","D","E","F"]

Explanation

Rationale for Correct Choices

• Swaddle the newborn in a blanket: Swaddling helps reduce heat loss through convection and evaporation, which is essential for a preterm newborn who has limited brown fat and poor thermoregulation. Maintaining warmth helps stabilize respiratory effort and metabolic demand. It is appropriate because the newborn’s temperature is below normal and continues to trend low.

• Dry the newborn: Drying reduces evaporative heat loss, which is a major risk immediately after birth, especially for late-preterm infants. Removing moisture from the skin supports temperature stabilization and reduces metabolic stress. This action is essential when temperatures remain below 36.5° C.

• Monitor the newborn’s vital signs: Frequent monitoring helps detect changes in temperature, heart rate, and respiratory drive, all of which can fluctuate rapidly in late-preterm newborns. Continuous monitoring allows the nurse to evaluate whether interventions for temperature and oxygenation are effective.

• Place the newborn under a radiant warmer: A radiant warmer provides controlled heat to support thermoregulation in preterm newborns who cannot maintain temperature independently. With temperatures at 36° C and 36.4° C, thermoregulation support is indicated to prevent cold stress. Radiant warming also helps stabilize oxygenation and metabolic rate.

• Administer free-flow oxygen: The newborn’s oxygen saturation is low at 90–91% on room air, indicating mild respiratory compromise. Providing free-flow oxygen improves oxygenation without requiring invasive airway management. This is appropriate for a newborn with increased respiratory effort but stable heart rate.

• Clear airway using bulb suction: Bulb suctioning is appropriate if secretions contribute to increased respiratory rate or difficulty maintaining saturation. Clearing the airway helps remove mucus that may impair airflow in preterm newborns. It supports spontaneous breathing and improves oxygenation.

Rationale for Incorrect Choices

• Initiate chest compressions: Chest compressions are only indicated when the newborn’s heart rate is below 60/min after at least 30 seconds of effective ventilation. This newborn’s heart rate is between 124–144/min, which is well above the threshold for resuscitation. Chest compressions are unnecessary and inappropriate for this clinical status.

• Place the newborn in prone position: Prone positioning is not recommended for routine stabilization and can compromise airway patency in a newborn requiring continuous monitoring. Supine or side-lying positioning reduces risk of airway obstruction and allows optimal chest expansion. Prone positioning increases risk for respiratory compromise in the acute period.

A. Allow extra time for the client to perform tasks. B. Touch the client gently to announce presence. C. Keep objects in the client's room in the same place. D. Approach the client from the side. E. Ensure there is high-wattage lighting in the client's room.

Correct Answer is ["A","C"]

Explanation

A. Allow extra time for the client to perform tasks: Clients with vision loss may require additional time to navigate their environment and complete activities safely. Providing extra time reduces stress, supports independence, and promotes a sense of autonomy while performing daily tasks.

B. Touch the client gently to announce presence: The nurse should announce presence verbally first. Touching without warning may startle the client.

C. Keep objects in the client's room in the same place: Maintaining a consistent arrangement of personal items prevents confusion and reduces the risk of falls or accidents. Predictable placement allows the client to perform tasks safely and maintain independence.

D. Approach the client from the side: Approaching from the side is not recommended because it may startle the client. Best practice is to approach from the front while using verbal cues to announce your presence and provide orientation.

E. Ensure there is high-wattage lighting in the client's room: High-intensity lighting may cause glare and discomfort for clients with vision loss, especially those with conditions like macular degeneration. Adequate but non-glare lighting is preferable to support safe mobility.

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A nurse is educating staff members on the laws governing voluntary admissions. Which of the following statements by a staff member indicates an understanding of the teaching?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is ["A","B","C","D","E","F"]

Explanation

A nurse is caring for a client who has vision loss. Which of the following actions should the nurse take? (Select all that apply.)

Correct Answer is ["A","C"]

Explanation

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