The nurse is triaging victims of a tornado at an emergency shelter. An adult who has been wandering and crying comes to the nurse. Which action should the nurse take?
Check the client’s temperature, blood sugar, and urine output.
Arrange for the client to be transported for laboratory tests and an electrocardiogram (ECG).
Delegate care of the crying client to an unlicensed assistant.
Direct the client to the shelter’s nutrition center to obtain water and food.
The Correct Answer is D
Answer and explanation
The correct answer is Choice D.
Choice A rationale
Checking the client’s temperature, blood sugar, and urine output could be important in certain situations, but in this case, it may not be the most immediate need. The client is wandering and crying, which suggests emotional distress rather than a physical health issue.
Choice B rationale
Arranging for the client to be transported for laboratory tests and an electrocardiogram (ECG) would be an overreaction in this situation. There’s no indication from the client’s behavior that they are experiencing a medical emergency.
Choice C rationale
Delegating care of the crying client to an unlicensed assistant is not the best choice. The client is likely experiencing emotional distress due to the traumatic event, and they would benefit from the care and attention of a trained professional.
Choice D rationale
Directing the client to the shelter’s nutrition center to obtain water and food is the best action in this situation. The client may be dehydrated or hungry, which could be contributing to their distress. Providing for these basic needs can help to calm the client and provide a sense of safety and stability.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Answer and explanation The correct answer is A. Choice A rationale
The client’s decision not to get the flu vaccine because they don’t get the flu demonstrates perceived barriers, one aspect of the Health Belief Model. The client may perceive that the potential discomfort or inconvenience of getting the vaccine outweighs the benefits.
Choice B rationale
Perceived susceptibility refers to an individual’s assessment of their risk of getting the condition. In this case, the client does not believe they are susceptible to the flu.
Choice C rationale
Perceived severity refers to an individual’s assessment of the seriousness of the condition and its potential consequences. The client has not expressed any beliefs about the severity of the flu.
Choice D rationale
Perceived benefits refer to an individual’s belief in the efficacy of the advised action to reduce risk or impact of the condition. The client has not expressed any beliefs about the benefits of the flu vaccine.
Correct Answer is A
Explanation
Answer and explanation
The correct answer is Choice A.
Choice A rationale
A graduate nursing student requesting information, including laboratory findings and chest X- ray results, about all clients with symptoms of H1N1 who have been seen during the last month in a community health clinic is asking for sensitive patient information. This information is protected under privacy laws and regulations, such as the Health Insurance Portability and Accountability Act (HIPAA) in the United States. Therefore, the charge nurse should obtain written authorization from clients to release the information. This ensures that the privacy and confidentiality of the patients are maintained, which is a fundamental principle in healthcare.
Choice B rationale
While it’s important to verify if permission has been obtained from the research committee, it’s not the first step in this process. The primary concern should be the patients’ rights to privacy and confidentiality. Therefore, obtaining written authorization from the clients to release their information should be the first step.
Choice C rationale
Asking the student to sign a standard waiver form is not sufficient to protect the privacy and confidentiality of the patients. The charge nurse should first obtain written authorization from the clients before releasing any information.
Choice D rationale
Providing the information for research purposes only does not absolve the healthcare provider from the responsibility of obtaining written consent from the patients. The patients’ rights to privacy and confidentiality must be respected, and their consent is necessary before any information can be released.
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