A nurse is orienting a newly licensed nurse on the neurological unit. Which of the following clients should the nurse assign to the newly licensed nurse?
A client who has Guillain-Barré syndrome and a tracheostomy
A client who has a brain tumor and is admitted for chemotherapy
A client who has multiple sclerosis and ataxia
A client who sustained a concussion and is being monitored for complications
The Correct Answer is D
Choice A Reason:
A client who has Guillain-Barré syndrome and a tracheostomy is incorrect. Guillain-Barré syndrome can be a complex condition, especially when accompanied by a tracheostomy. Caring for a client with this condition requires knowledge and experience in managing respiratory and neurological complications. It may not be suitable for a newly licensed nurse who may require more experience to manage such complex care needs.
Choice B Reason:
A client who has a brain tumor and is admitted for chemotherapy is incorrect. Caring for a client with a brain tumor undergoing chemotherapy involves understanding the effects of both the tumor and the treatment on the client's neurological status and overall well-being. It may require advanced assessment skills and knowledge of potential complications. Assigning this client to a newly licensed nurse may not be appropriate without additional support and supervision.
Choice C Reason:
A client who has multiple sclerosis and ataxia is incorrect. Multiple sclerosis (MS) can present with various neurological symptoms, including ataxia, which affects coordination and balance. Managing the care of a client with MS and ataxia may require familiarity with the disease process, symptom management strategies, and potential complications. It may be more suitable for a nurse with some experience in neurological nursing.
Choice D Reason:
A client who sustained a concussion and is being monitored for complications is correct. Caring for a client with a concussion being monitored for complications is typically within the scope of practice for a newly licensed nurse. Monitoring for changes in neurological status, assessing for signs of increased intracranial pressure, and providing supportive care are tasks that can be managed by a newly licensed nurse under appropriate supervision.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A Reason:
"I will have a nurse witness the signing of my living will." This statement is incorrect. While having a witness present during the signing of a living will is important for validity in some jurisdictions, the statement alone does not demonstrate an understanding of advance directives. It's essential to ensure that the client comprehends the purpose and content of the document, not just the procedural aspect.
Choice B Reason:
"I can make changes to my living will even after I sign it." This statement is correct. Understanding that living wills can be revised or updated as needed reflects comprehension of the flexibility and control that advance directives provide. It's crucial for clients to know that they can make changes to their directives if their preferences or circumstances change.
Choice C Reason:
"I should choose a family member as my health care proxy." This statement is incorrect. While selecting a family member as a health care proxy is a common choice, it may not necessarily indicate an understanding of advance directives. The key aspect is that the client understands the role of the health care proxy and chooses someone who can make decisions aligned with their wishes.
Choice D Reason:
"I need to have my attorney review my advance directives." This statement is incorrect. While it can be beneficial to have an attorney review advance directives for legal clarity and compliance with state laws, it is not a requirement for their validity. The statement alone does not demonstrate understanding of advance directives.
Correct Answer is A
Explanation
Choice A Reason:
Clients on airborne precautions (e.g., for tuberculosis, varicella, or measles) should wear a mask if they need to leave their room to prevent the spread of airborne pathogens to others. This helps to contain infectious particles and protect others from exposure.
Choice B Reason:
A client with compromised immunity should be placed in a positive-pressure airflow room, not a negative-pressure room. Positive-pressure rooms help prevent outside contaminants from entering the room, thereby protecting the immunocompromised client. Negative-pressure rooms are used for clients with airborne infectious diseases to prevent the spread of pathogens to other areas.
Choice C Reason:
Contact precautions typically involve wearing gloves and a gown to prevent the spread of infectious agents through direct contact. Masks are not generally required for visitors unless the client is also on droplet or airborne precautions. Therefore, this statement reflects a misunderstanding of the specific requirements for contact precautions.
Choice D Reason:
An N95 respirator mask is required for airborne precautions, not droplet precautions. For droplet precautions (e.g., for influenza, pertussis), a standard surgical mask is sufficient to protect against respiratory droplets.
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