QUESTION 66 A toddler has been brought to the Emergency Room by the parents. Upon assessment the RN notices round-shaped burn marks on the upper arms…


A toddler has been brought to the Emergency Room by the parents. Upon assessment the RN notices round-shaped burn marks on the upper arms and thighs of the patient. What is the legal responsibility of the RN at this time?

a.           Identify the marks as cigarette burns and confront the parents.

b.           Call the police and have the parents arrested.

c.            Contact child protective services and detain the child from discharge.

d.           Treat the patient and follow-up with child protective services once the family has returned home.


The RN has selected Chronic low self-esteem as the priority nursing diagnosis for a client admitted with a medical diagnosis of Depression. Which intervention is appropriate for this nursing diagnosis?

a.           Ensure environment is safe.

b.           Assess stage of grieving process.

c.            Establish trusting relationship.

d.           Maintain close observation.


What is the RN’s most appropriate response to a client who is experiencing a Post-Traumatic Stress Disorder (PTSD) reaction?

a.           “You are safe here and in good hands.”

b.           “You probably think you are back in a war zone.”

c.            “It’s not that bad, try to relax.”

d.           “Tell me what you are experiencing right now.”


A client with Borderline Personality Disorder has been exhibiting frequent, violent temper outbursts on the mental health unit. Which outcome would be most appropriate for this client?

a.           Client will express anger appropriately.

b.           Client will stop exploiting others on the unit.

c.            Client will be able to express his emotions.

d.           Client will interact with others on the unit.


Which data would the RN expect to assess for a patient with Alzheimer’s Disease? Select all that apply.

a.           Safety due to wandering.

 b.          Increase in alertness.

 c.           Decline in short-term memory.

 d.          Depressed affect.

 e.          Ability to read books. 


A client’s health record indicates Stage 4 Alzheimer’s disease with recent episodes of confabulation. The RN instructs the LPN on the team to report if which of the following client behaviors is noticed?

 a.          Exhibits short-term memory loss.

 b.          Makes up things to fill in memory gaps.

 c.           Acts in an inappropriate manner.

 d.          Becomes disoriented at night.


What is the appropriate RN response when the family of a patient diagnosed with Alzheimer’s Disease asks the RN why it is necessary to have referrals to other types of healthcare providers?

a.           “Symptoms will get worse and then improve.”

b.           “There will be a change in cognition and ability to function.”

c.            “The care involves excessive work for one provider.”

d.           “Alzheimer’s will impact vital physical functioning.”

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