A nurse observes another nurse acting flirtatiously and bringing small gifts, such as candy, to a client in the behavioral health unit. Which action is a priority by the observing nurse?

In order to protect the rights of the client, the nurse should report the behavior to the supervisor.

The client is entitled to have a relationship with anyone and the nurse should ignore the behavior.

The nurse should confront the nurse and tell them the behavior must immediately stop.

Discuss this with the client and tell them they are being emotionally manipulated.

Answer and Explanation

The Correct Answer is A

When a nurse observes another nurse acting flirtatiously and bringing small gifts to a client in the behavioral health unit, it raises concerns about professional boundaries and the potential for unethical behavior. The priority action for the observing nurse is to protect the rights and well-being of the client.

Option A, reporting the behavior to the supervisor, is the appropriate course of action. Reporting the observed behavior to the supervisor ensures that the situation is investigated and addressed by the appropriate authorities within the healthcare facility. This action helps maintain the integrity of the therapeutic relationship between the client and healthcare team and protects the client from any potential exploitation or manipulation.

Options B, C and D are not appropriate actions:

B. Ignoring the behavior is not appropriate as it does not address the concerns about professional boundaries and the potential for unethical behavior. Ignoring such behavior may allow it to continue, potentially putting the client at risk.

C. Confronting the nurse directly without first reporting the behavior to the supervisor may not be the most appropriate course of action. It is essential to involve the appropriate authorities within the healthcare facility to conduct a proper investigation and address the situation professionally.

D. Discussing the situation with the client and making assumptions about emotional manipulation may not be appropriate or accurate. It is not the observing nurse's role to discuss such matters with the client. Instead, the appropriate course of action is to report the observed behavior to the supervisor or appropriate authority within the healthcare facility.

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Correct Answer is D

Explanation

When a school nurse suspects that a child is being sexually abused, the priority action is to ensure the child's safety and well-being. Option D, accurately and thoroughly documenting the findings and reporting to the appropriate authorities, is the most critical step in protecting the child.

Child abuse, including sexual abuse, is a serious concern that requires immediate attention and intervention. In many jurisdictions, healthcare professionals, including school nurses, are mandated reporters, which means they are legally obligated to report suspected cases of child abuse to child protective services or other appropriate authorities.

Options A, B, and C are not appropriate as the child's safety is the top priority:

A. Discussing the findings with the parents and giving them the opportunity to explain could potentially place the child at further risk if the parents are involved in the abuse or are unwilling to address the situation.

B. Talking to the child and finding out if they are experiencing sexual abuse or inappropriate touching should not be the first step without involving child protective services or other appropriate authorities. The child may be frightened or reluctant to disclose abuse directly to the nurse, especially if the abuser is a family member or someone known to the child.

C. Talking with another co-worker to confirm the assessment may delay the necessary action and reporting to protect the child.

A. Blood pressure B. Cyanosis C. Nausea D. Petechiae

Correct Answer is C

Explanation

Objective data:

Blood pressure (can be measured by the nurse)

Cyanosis (can be observed by the nurse)

Petechiae (can be observed by the nurse)

So, the subjective data in this list is "Nausea." This is information that the client shares with the nurse about their symptoms or feelings.

The objective data includes A-"Blood pressure," B-"Cyanosis," and D-"Petechiae," which are findings that the nurse can measure or observe during the physical examination.

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A nurse observes another nurse acting flirtatiously and bringing small gifts, such as candy, to a client in the behavioral health unit. Which action is a priority by the observing nurse?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The school nurse is seeing a 7-year-old child in the clinic and is concerned with behaviors and physical indications that indicate the child is being sexually abused. Which is the priority action by the nurse?

Correct Answer is D

Explanation

A nurse is completing a client's history and physical examination. Which of the following information should the nurse consider subjective data?

Correct Answer is C

Explanation

A client with depression is admitted for voluntary treatment. While in the hospital, the client makes several comments about leaving the facility and kiling themselves with their gun. Which is the most appropriate action by the nurse when the client requests to leave against medical advice?

A client has just had an elective abortion to end an unintended pregnancy. Afterward, the client cries because although they wanted to have children in future years, this pregnancy was not well timed. Which type of grief is this client most likely to experience?

The nurse is working with another nurse in the emergency department (ED) when a client comes in stating they have been raped during a date. Which statement made by the other nurse privately requires immediate correction?

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