Mental Health Case Stude

Post Result Begin Again 100% Correct Let's review your results from 1/15/2022 at 1:41 pm PST Correct Incorrect Question 1 of 28 As the nurse documents the client’s assessment, the nurse is correct to question which activity of a client with type II diabetes mellitus?(Select all that apply. One, some, or all options may be correct.) Select all that apply Client’s frequency for checking blood glucose. Too much glucose in the system can cause long-term complications such as heart disease. Understanding how the client manages his diabetes can provide helpful insight on the treatment plans and how to prevent further complications. Quantity of Ensure taken per day. Reviewing the amount of nutrition shakes the client consumes daily helps the nurse discern if proper caloric intake is taking place as well as assess the client’s nutritional status. Reason for lack of appetite. If a person taking insulin fails to consume adequate carbohydrates, a drop in glucose levels is possible, causing hypoglycemia (low blood glucose). Symptoms of hypoglycemia include headache, disorientation, weakness, perspiration, shallow breathing, nervousness, visual disturbances, and vertigo, and it sometimes leads to unconsciousness. Christensen, Barbara L.(2010). Foundations of Nursing, 6th Edition. Mosby, page 639. Amount of water and other fluids taken daily. Clients with diabetes require more fluid intake to avoid dehydration because high levels of glucose can lead to dehydration. Rebar, C., Ignatavicius, D., Workman, M. L. (2018). Medical-Surgical Nursing: concepts for nterprofessional collaborative care, (9th ed.) St. Louis, MO, p. 195. Last blood glucose result obtained by client. This would be the least concern because the nurse is going to take the client’s blood glucose as part of the initial assessment. Question 2 of 28 The client mentions that he feels “blue” lately because his wife died one year ago, and his children live out of state and seldom visit. The nurse knows that the greatest risk for major depression includes which event? Being retired from the military. Retirement can be a source of depression but is not the greatest risk. The realization of growing older. Adapting to old age depends on personality traits and coping strategies and is not considered the greatest risk for depression. Ignatavicius, D., Workman, M. L. (2013). Medical-Surgical Nursing: Patient-Centered Collaborative Care, (7th ed.), Saunders, St. Louis, MO, Elsevier, Inc., p. 15. Inability to attend church regularly. Inability to participate in spiritual activities that were once enjoyed can sometimes negatively affect an elderly person. The client has not mentioned the inability to participate in activities he once enjoyed. Becoming widowed within the past year. The combinations of sadness, loneliness from losing a loved one in widowhood, and hopelessness leads to social withdrawal. Those feelings place an older adult at greater risk of suffering from major depression because older adults are reluctant to adapt to changes. Ignatavicius, D., Workman, M. L. (2013). Medical-Surgical Nursing: Patient-Centered Collaborative Care, (7th ed.), Saunders, St. Louis, MO, Elsevier, Inc., p. 15. Question 3 of 28 The HCP prescribes 1000 mL dextrose 5% with normal saline 0.9% and 20 mEq/L potassium chloride (KCl) to infuse at 100 mL/hr. The nurse is correct to question which additive to this infusion prescription? Normal saline (NS) and Potassium chloride (KCl). The combination of potassium and calcium in the IV fluids assists to replenish electrolytes in the body. Normal saline (NS). Normal saline is prescribed to replete volume not to treat a glucose. Dextrose (D5). Solutions that contain dextrose are not recommended for client with diabetes because they can result in the rise of insulin, which will cause a decreased level of potassium in the blood. Dextrose may be prescribed for a client with diabetes to prevent low blood sugar during surgery. As a result of the many treatment and approaches to diabetes, it is important for the nurse to clarify the drug and intravenous fluid prescriptions with the HCP. Potassium chloride (KCl). There appears to be a link between levels of potassium and glucose. Question 4 of 28 The HCP prescribes 1000 mL normal saline 0.45% with 20 mEq/L potassium chloride (KCl) to infuse at 125 mL/hr. The nurse calculates that it will take how many hours for the infusion to be complete? (Enter numeric value only. If rounding is required, round to the whole number.) Total volume infused/mL per hour = infusion time. 1000 mL/125 mL = 8 hours Question 5 of 28 The client is febrile with temperature of 101.5°F (38.6°C). Based on this information, which intervention should the nurse implement first? Contact the lab and request blood cultures be drawn. Blood culture specimens are always drawn before giving acetaminophen or starting antibiotic therapy because the antibiotic usually interferes with the organism's growth in the laboratory. Christensen, B. L. (2011). Foundations of Nursing, (6th Edition), St. Louis, MO, Elsevier, Inc., P.508. Administer acetaminophen per hospital protocol. To maintain the accuracy of a clinical picture, blood cultures are generally obtained prior to medicating clients. Acetaminophen is an antipyretic and is withheld because it lowers the body’s temperature and suppresses some of the body’s natural responses to infection, affecting the blood culture results. Christensen, B. L. (2011). Foundations of Nursing, (6th Edition), St. Louis, MO, Elsevier, Inc., P.508. Contact the HCP for a prescription for an antibiotic. The initiation of antibiotic treatment is always withheld until after the blood culture is drawn because the accuracy of the results may be affected. Christensen, B. L. (2011). Foundations of Nursing, (6th Edition), St. Louis, MO, Elsevier, Inc., P.508. Retake temperature with a tympanic thermometer. The temperature is usually retaken to measure the efficacy of the antipyretic. Christensen, B. L. (2011). Foundations of Nursing, (6th Edition), St. Louis, MO, Elsevier, Inc., P.508. Question 6 of 28 The HCP prescribes clindamycin 900 mg in 100 mL over 30 minutes. The IV tubing drop factor is 15 gtt/mL. The nurse should regulate the IV to deliver how many drops per minute? (Enter numeric value only. If rounding is required, round to the nearest Use the formula: volume over time in minutes X the drop factor 100 mL/hr / 30 minutes X 15 gtt/mL = 49.9 = 50 gtts/min whole number.) Question 7 of 28 The nurse knows that before drawing arterial blood gases, which interventions are the most important to be performed?(Select all that apply. One, some, or all options may be correct.) Select all that apply Perform Allen’s Test. The Allen’s test is performed prior to drawing an arterial blood test. It involves the nurse compressing both radial and ulnar arteries at the same time. The client’s hand should become white as a result of the occlusion. The client’s hand color should return as soon as the nurse releases both arteries. Black, J. M. (2009) Medical-Surgical Nursing: Clinical Management for Positive Outcomes. (8th ed.), St. Louis, MO, Elsevier, Inc., p. 180. Use sterile technique. Sterile technique must be maintained during venipuncture. Black, J. M. (2009) Medical-Surgical Nursing: Clinical Management for Positive Outcomes. (8th ed.), St. Louis, MO, Elsevier, Inc., p. 180. Utilize clean technique. Medical asepsis is used in many daily activities, such as hand hygiene and changing clients’ bed linens. Sterile technique, not clean technique, is always used in an invasive procedure. Check two client identifiers. The two client identifier is part of the Joint Commission’s National Patient Safety Goals and requires the nurse to verify two identifiers prior to performing any procedure to ensure the right client and procedure. Black, J. M. (2009) Medical-Surgical Nursing: Clinical Management for Positive Outcomes. (8th ed.), St. Louis, MO, Elsevier, Inc., p. 180. Draw blood gas after applying oxygen. Arterial blood gas (ABG) findings interpret the client’s oxygenation and acid-base balance. The result of the ABG will measure if the applied oxygen is actually helping the client, if there is a need to obtain an order for bicarbonate. Question 8 of 28 When monitoring the client’s respiratory status, which symptom provides the nurse with the earliest indication of respiratory difficulty? Hypoxia. Hypoxia is an early sign of respiratory distress. The nurse assesses respiratory depth, rate, and effort and listens for abnormal breath sounds that suggest breathing difficulty. Ignatavicius, D., Winkelman, C. (2016). Clinical Companion for Medical-Surgical Nursing: patient—centered care, (8th ed.), St. Louis, MO, Elsevier, Inc. p. 570. Dusky nail beds and lips. Dusky nail beds and lips are late signs of respiratory distress. Decreased pulse rate. The pulse rate will increase with respiratory difficulty. Cyanosis. Cyanosis is a late sign of respiratory distress. Question 9 of 28 The nurse prepares to contact the HCP with lab results, knowing that all lab information must be collected prior to reporting. Which lab results does the nurse need to report first to the HCP? Arterial Blood Gases (ABGs), O2 saturation, White Blood Cell Count (WBC). Normal values for adults are pH 7.35 to 7.45 , PaCO2 35 to 45 mmHg (4.6 - 5.9 kPa), PaO2 80 to100 mmHg (>10.6 kPa), HCO3 22 to 26 (22-26 mmol/L), O2 saturation 96% to 100%. The labs for the client are abnormal. As COPD worsens, oxygen in the blood decreases and carbon dioxide increases, resulting in chronic respiratory acidosis. Once baseline ABG values are obtained and communicated to the HCP, treatment and monitoring can begin. The WBC count is high and is indicative of possible infection which should be reported to the HCP. Ignatavicius, D., Workman, M. L. (2016). Medical-Surgical Nursing: patient-centered collaborative care. (8th ed.), St. Louis, MO, Elsevier, Inc., p. 188. Potassium (K+), Chloride (Cl), Creatinine (Cr). These labs are normal and there is no need to report the results. Glucose, HCO3, Blood Urea Nitrogen (BUN). The blood glucose is abnormal but the HCP is already aware of this from Mr. Fearon’s initial assessment and is not the most important lab to report. The other lab values are normal and there is no need to report them. Platelets, Sodium (Na+), Hemoglobin (HG)/Hematocrit (Hct). These lab values are normal and there is no need to report the results. Question 10 of 28 The nurse should interpret which finding as expected limits for the client with COPD? 87% O2 saturation. A client with COPD who retains CO2 has adapted to high blood CO2, and relies on low PaO2 to stimulate breathing. A high concentration of O2 may raise the PaO2 level so that the client’s stimulus to breathe is lost and respiratory depression may result. Not all clients with COPD rely on hypoxic drive; retention of CO2 must be confirmed by blood gas analysis. Reference: Linton, A. (2012). Introduction to Medical-Surgical Nursing, (5th Edition). St. Louis, MO, Elsevier, Inc. p. 557. 96% O2 saturation. This result is within the normal range and not an expected finding from a client with COPD. 100% O2 saturation. This result is within the normal range and not an expected finding from a client with COPD. 75% O2 saturation. This result is below the range for any client and requires immediate oxygenation intervention. Question 11 of 28 The HCP orders additional diagnostic tests. Which test would the nurse anticipate the HCP will order for the client? Magnetic Resonance Image (MRI). A magnetic resonance image (MRI) is used to view anatomical structures and detect abnormalities. It gives the clinician a 3-d image, however, bones are not well-identified in MRI images. MRI is a noninvasive examination that does not expose the client to radiation and produces precise, clear images of tumors. Linton, A. (2012). Introduction to Medical-Surgical Nursing, 5th Edition. (8th ed.) St. Louis, MO, Elsevier, Inc., p. 547. Positron Emission Tomography (PET). A position emission tomography (PET) utilizes a radioactive tracer that allows the clinician to detect diseases and proper organ function. Exposure to radiation is greater than an MRI and takes longer to perform, 3-4 hours. Linton, A. (2012). Introduction to Medical-Surgical Nursing, 5th Edition. (8th ed.) St. Louis, MO, Elsevier, Inc., p. 550. Computerized Tomography (CT). A computerized tomography (CT) is the diagnostic imaging of choice during emergent situations because it produces accurate images of solid organs and bones that can reveal soft tissue masses. It is considered more harmful due to the side effects of radiation exposure. Linton, A. (2012). Introduction to Medical-Surgical Nursing, 5th Edition. (8th ed.) St. Louis, MO, Elsevier, Inc., p. 547. Diagnostic Imaging X-ray (DIX). This is not a legitimate test that would be ordered for the client. Question 12 of 28 What are the nurse’s responsibilities when preparing the client for the CT scan?(Select all that apply. One, some, or all options may be correct.) Select all that apply Verify the client’s identity with two types of identifiers. The client is identified with two types of identifiers before any procedure is performed. https://www.jointcommission.org/NPSG.01.01.01 Determine if the client has any known allergy to iodine or shellfish. It is the nurse’s responsibility to always assess the client for allergies to the iodine dye before it is administered. Christensen, B. L. (2011). Foundations of Nursing. (6th ed.) St. Louis, MO., Elsevier, Inc. p. 479. Ask the client when his last dose of metformin was taken. If the client usually takes metformin, the drug is stopped at least 24 hours before contrast dye is used and is not restarted until adequate kidney function has been established. Explain the post procedure and the recovery time. There is no post procedure to explain for this procedure. Instruct the client to remain NPO 4 to 8 hours before the procedure. It is not necessary for a client to be NPO prior to this procedure. Christensen, B. L. (2011). Foundations of Nursing. (6th ed.) St. Louis, MO., Elsevier, Inc. p. 479. Question 13 of 28 A client care technician arrives to transport the client to the CT scan. The nurse knows that communication breakdown can occur during transfer. Which statements about effective handoff communication are true?(Select all that apply. One, some, or all options may be correct.) Select all that apply Background noise and interruption seldom affect the exchange of information because nurses can multitask. Background noise and interruption always affect the exchange of information and can lead to miscommunications that cause medical errors. Ignatavicius, D., Winkelman, C. (2016). Clinical Companion for Medical-Surgical Nursing: patient-centered collaborative care. (8th ed.), St. Louis, MO., Elsevier, Inc. p. 67. There is no need to give a verbal report if the situation, background, assessment recommendation (SBAR) tool is used. Verbal communication is a two-way conversation between two providers, which minimizes misunderstandings and potential client medical errors. Ignatavicius, D., Winkelman, C. (2016). Clinical Companion for Medical-Surgical Nursing: patient-centered collaborative care. (8th ed.), St. Louis, MO., Elsevier, Inc. p. 67. Communication and tradition differences between people of different backgrounds can be a barrier to handoff. To improve communication between staff members and healthcare agencies, procedures for handoff communication were established. Ignatavicius, D., Winkelman, C. (2016). Clinical Companion for Medical-Surgical Nursing: patient-centered collaborative care. (8th ed.), St. Louis, MO., Elsevier, Inc. p. 67. A situation, background, assessment recommendation tool form must be completed prior to the client’s transfer. An effective procedure used in many agencies today is called SBAR (pronounced S-Bar). SBAR is a formal method of communication between two or more members of the healthcare team. Ignatavicius, D., Winkelman, C. (2016). Clinical Companion for Medical-Surgical Nursing: patient-centered collaborative care. (8th ed.), St. Louis, MO., Elsevier, Inc. p. 67. A situation, background, assessment recommendation (SBAR) tool is used only between the nurse and the HCP to obtain orders for client care. The SBAR communication method is used between all interdisciplinary care providers to ensure accurate and safe communications about client care. Ignatavicius, D., Winkelman, C. (2016). Clinical Companion for Medical-Surgical Nursing: patient-centered collaborative care. (8th ed.), St. Louis, MO., Elsevier, Inc. p. 67. Question 14 of 28 When preparing the client for the bronchoscopy, it isessentialfor the nurse to take which action first? Instruct the client to be NPO for 4 to 8 hours before the procedure. Abstaining from food or liquids hours before a procedure can decrease the risk of pulmonary aspiration but is not the first action. Christensen, B. L. (2011). Foundations of Nursing. (6th ed.), St. Louis, MO, Elsevier, Inc., Page 479. Premedicate the client with the prescribed benzodiazepine prior to the procedure. If there is a prescription to premedicate the client prior to a procedure, the consent form must be signed first and the client must understand the procedure prior to administration of the medication. Christensen, B. L. (2011). Foundations of Nursing. (6th ed.), St. Louis, MO, Elsevier, Inc., Page 479. Provide detailed information about the procedure to the client. Educating a client regarding the care prior to and after a procedure can ease concerns a client may have about the procedure. The nurse is not responsible for providing detailed information about the procedure but is to clarify facts that have been presented to the client by the healthcare provider. Christensen, B. L. (2011). Foundations of Nursing. (6th ed.), St. Louis, MO, Elsevier, Inc., Page 479. Verify that the consent form is signed by the client and witness the signature. By witnessing the client sign the informed consent, the nurse can confirm that the client has all of his concerns addressed and that he understands the procedure and risks associated with it. It is essential to obtain informed consent before sedation for surgery or a procedure is performed and is the first action taken by the nurse. The nurse is to verify that the consent form is signed and serve as a witness to the signature[FS(1] . Ignatavicius, D., Workman, M. L. (2018). Medical-Surgical Nursing: patient-centered collaborative care, (8th Edition), St. Louis, MO., Elsevier, Inc. p. 239. Question 15 of 28 Which legal document ensures that the client’s treatment preferences are followed in the event that he is unable to make decisions regarding his own care? Advance Directives. An advance directive is a document that allows clients to name someone they trust to act on their behalf if they are ever unable to make healthcare decisions for themselves. Living will. A living will is a legal document that allows clients to designate in advance, which treatments they want in specific situations. Durable Power Of Attorney. The Durable Power of Attorney allows clients to designate in advance, one person to make treatment decisions when clients are not able to make decisions for themselves. A durable power of attorney can gain access to medical records, withhold treatment if a court order is obtained, hire or fire medical personnel, and refuse or consent for treatment. This authority ends with death of the client. Advance living will. This is not a legal document. Question 16 of 28 After listening to the chaplain ask the client questions, which is themostimportant factor that positively influences the client’s ability to cope with his illness? Unconscious defense mechanisms. Defense mechanisms are used in an effort to diminish anxiety; however, when used excessively or inappropriately, they can hinder a client’s ability to cope with illness. Spirituality. To determine whether spirituality is an asset or a liability to a client's ability to cope with illness, it is important to understand that all individuals are experts about his or her own spiritual needs and paths. Clients need an opportunity to express their feelings in a therapeutic and nonjudgmental environment. The role of the nurse is to listen, support, and care. Minimizing the severity of the illness. Denial is the subconscious blocking out of emotional experiences and is not acceptable method of coping. Using logic and reasoning to avoid unacceptable feelings. Rationalization or intellectualization is the use of logic and reasoning to avoid unacceptable feelings. This is not a positive influence on coping with illness. Question 17 of 28 The client doesn’t understand the reason why he has to meet with a chaplain and a case manager. He states that he is fine and does not need any charity help. The client does not understand the role of a case manager. Which instruction by the nurse best describes the role of a case manager? A case manager measures the effectiveness of the hospital staff caring for the client. This is not the function of the case manager. A case manager provides a list of resources, services, or support to help the client. The purpose of the case management process is to provide quality and cost-effective services and resources to achieve positive client outcomes. Ignatavicius, D., Workman, M. L. (2016). Medical-Surgical Nursing: Patient-Centered Collaborative Care, (8th ed.), Elsevier; St. Louis, MO, Elsevier, Inc. p. 5. A case manager only works with older clients during terminal illness. A case manager may work with older clients during terminal illness but this is not a complete description of the role of the case manager. A case manager’s scope restricts them to only work in community based setting. This does not accurately reflect the role of the case manager as they work in all settings of nursing, especially the community-based setting. Question 18 of 28 The Medicare Hospice Benefit serves as a guide for hospice care in the United States. Based on this guide, which criteria does the client have to meet in order to qualify for this benefit?(Select all that apply. One, some, or all options may be correct. Select all that apply Have a prognosis of 6 months or less to live. Medicare Hospice Benefit pays for hospice services for Medicare recipients who have a prognosis of 6 months or less to live. Ignatavicius, D., Workman, M. L. (2016). Medical-Surgical Nursing: Patient-Centered Collaborative Care, (8th ed.), St. Louis, MO, Elsevier, Inc. p. 106. Have a prognosis of 8 months to live then agree to recertify. The client must have a 6 months or less prognosis to qualify for initial hospice benefits or to recertify. Agree to curative treatment for terminal illness. The client must forego curative treatment to qualify for hospice benefits. Ignatavicius, D., Workman, M. L. (2016). Medical-Surgical Nursing: Patient-Centered Collaborative Care, (8th ed.), St. Louis, MO, Elsevier, Inc. p. 106. Forego curative treatment for terminal illness. Qualification for hospice benefits requires the client to agree to forego curative treatment for their terminal illness. Ignatavicius, D., Workman, M. L. (2016). Medical-Surgical Nursing: Patient-Centered Collaborative Care, (8th ed.), St. Louis, MO, Elsevier, Inc. p. 106. Choose a Medicare-approved hospice provider. The client must select a Medicare-approved hospice provider to receive hospice benefits. Ignatavicius, D., Workman, M. L. (2016). Medical-Surgical Nursing: Patient-Centered Collaborative Care, (8th ed.), St. Louis, MO, Elsevier, Inc. p. 106. Question 19 of 28 The client states, "I am so sick of fighting to breathe and just trying to survive. I am alone and I am a burden. I have lived a good life and am ready to go." Which statement is accurate? Older clients should never be taken seriously when mentioning they are sad. Any mention of sadness or suicide by an older individual should be taken seriously and reported to a HCP or to senior nursing staff, if the client is hospitalized. Evans K.,Nizzette, D., O'Brien, A., (2017). Psychiatric & Mental Health Nursing, (4th ed.), Chatswood, NSW., Elsevier, Inc., p. 277. There is no need to need to worry about suicide attempts if the client is hospitalized. The risk of suicide in the older population is very real and should never be discounted as a possibility. All the research on depression medication indicates that it is not effective for geriatric clients. Pharmacotherapy (e.g. antidepressants, antipsychotics) and electroconvulsive therapy (ECT) may be prescribed and used alone or in conjunction with psychosocial therapies. Although depression may be greatly improved with pharmacotherapy, it is imperative that older clients are monitored for medication side effects. Comments geriatric clients make of feeling depressed or wanting to commit suicide should be reported. The nurse should never assume because a client is an older person and hospitalized, or in a nursing home, that they are not capable of hoarding medications or using some other means to fulfill a suicide attempt. Evans K.,Nizzette, D., O'Brien, A., (2017). Psychiatric & Mental Health Nursing, (4th ed.), Chatswood, NSW., Elsevier, Inc., p. 277. Question 20 of 28 The client continues to say that he gets no enjoyment out of life, and now with the illness, he feels life is no longer worth living. To determine the seriousness of his risk for attempting suicide, which information ismostimportant for the nurse to obtain? Determine when the client first started feeling this way. This is a valid assessment but not the most important. Ask the client the name of his psychiatrist. This is a valid assessment but not the most important. Assess the client for activities that he enjoys. This is a valid assessment but not the most important. Identify if the client has a suicide plan. If a client offers information about an intended suicide, identifying how, when, and by what means, this will enable the level of risk to be assessed. Personality, physical illness, and recent bereavement are known contributing factors to suicide in older people who are not suffering from psychiatric illness at the time of death. Halter, M. Varcarolis' Foundations of Psychiatric Mental Health Nursing. (7th ed.), St. Louis, MO, Elsevier, Inc., p. 123. Question 21 of 28 The client scores an 8 on the Modified Sad Persons Scale (MSPS). Based on policy, the client must be placed on suicide precautions. Which action isbestfor the nurse to keep the client safe? Round hourly checking and observing the client when placed on suicide watch. The intensity of observations varies depending on the clinical assessment. Clients who are more acutely unwell may need to be sighted more frequently; every 15 to 30 minutes. In the client's case, this is not appropriate. Monitor the client constantly, but allow meals in private. The client may be sighted at regular intervals, for example, at the start and the end of the shift, but this is not an appropriate level of intervention for a client with the score of 8 on the MSAS. It is also not appropriate to leave the client alone with meal utensils. Provide a quiet environment by leaving the client’s door closed. Leaving the client alone with the door closed is not an appropriate level of intervention for a client who is rated 8 on the MSPS. One-on-one monitoring with staff at arm’s length at all times. Suicide precautions are an appropriate intervention for theclient and include one-on-one monitoring with a staff member at arm’s length at all times. The client verbalizes that he believes his situation is intolerable and leads to feelings of hopelessness. Therefore, hopelessness is most often a crucial phenomenon requiring this intervention. Halter, M. Varcarolis' Foundations of Psychiatric Mental Health Nursing. (7th ed.), St. Louis, MO, Elsevier, Inc., p. 123. Question 22 of 28 Which behavior is a warning to the nurse that the client has decided to carry out a suicide plan and that the action is imminent? The client continuously requests pain medication. Continuously requesting pain medication is not necessarily an imminent sign of suicide. However, the nurse needs to contact the HCP to adjust the pain medication to achieve a more favorable outcome. The client has multiple psychiatric conditions. The client does not have an extensive psychiatric history. However, multiple psychiatric conditions does not indicate suicide is imminent. The client expresses sadness and unhappiness with life. Worsening signs such as increasing withdrawal, preoccupation, silence, remorse, and sudden change from sad to happy and “worry-free” raises a red flag of imminent suicide. The client suddenly goes from depressed to happy. A red flag is raised if the client suddenly goes from sad and depressed to happy and seemingly peaceful. Often a decision to commit suicide gives a way out of severe emotional pain. Halter, M. Varcarolis' Foundations of Psychiatric Mental Health Nursing. (7th ed.), St. Louis, MO, Elsevier, Inc., p. 468. Question 23 of 28 Such events are considered "sentinel" because there is an immediate need for investigation and response to the unexpected death of a client. What were the defining characteristics of the client's impending suicide and indications that he should not have been left alone?(Select all that apply. One, some, or all options may be correct.) Select all that apply Deteriorating physical condition. The client verbalized his lack of enjoyment in life, his deteriorating physical condition, and how he feels his life is no longer worth living. Requests for social isolation. Social isolation is a related factor but not related to this client according to his history. Severe loss of relationships. The severe loss of the client’s spouse contributes to his mounting depression. Loss of beliefs and spiritual power. Lost beliefs and spiritual power are also related factors but are not related to this client according to his history. Perceiving the future as bleak and wasted. Mr. Fearon perceives the future as bleak and wasted and verbalizes that his life is no longer worth living. Question 24 of 28 The charge nurse determines the appropriate delegation of tasks on the unit. How should the charge nurse initially respond to staff members after the client's suicide? Accept responsibility of leadership and delegation. Delegation is a management tool that nurses use at their discretion. Effective delegation requires delegating a clearly identified task and related time frames, validating understanding, identifying client needs, empowering the staff person to carry out activities to complete the task, and monitoring staff performance. A good leader and manager accepts responsibility of leadership and delegation and is responsible for training staff. Linton, A. (2012). Introduction to Medical-Surgical Nursing, (5th ed.), St. Louis, MO, Elsevier, Inc., p. 32. Advise the staff members to seek legal counsel. Healthcare institutions commonly provide malpractice insurance for nurses they employ and this coverage generally covers legal fees and awards if a nurse is sued for professional negligence or medical malpractice. However, this is not the charge nurse’s initial response. Discuss the need for the team to communicate more effectively. Discussions of the need for the team to communicate more effectively are in order but not the immediate response by the charge nurse. Direct the team to agree on a better method to schedule break times. Directing the team to agree on a better method to schedule break times is a future discussion, not an immediate action by the charge nurse. Question 25 of 28 The client is overcome with the sight of her deceased father and begins to cry. Which therapeutic approach isbestfor the nurse to facilitate expression of grief? Empathizing with the family member by being present to provide emotional support. The best nursing intervention is to be physically and psychologically present with a grieving client, empathizing to provide emotional support. Presence includes listening and acknowledging the legitimacy of the family member’s pain and is often more therapeutic than speaking. References: Ignatavicius, D., Workman, M. L. (2013). Medical-Surgical Nursing: PatientCentered Collaborative Care, 7th Edition. [Bookshelf Online]. Retrieved from https://online.vitalsource.com/#/books/978-1-4377-2801-9/P. 116 Facilitating grief by assuring the family member that everything will be fine. Avoid trite reassurance and accept the client’s feelings. Attempting to explain the loss in philosophical or religious terms. Do not try to explain the loss in philosophical or religious terms. Arrange for counseling with chaplains or others trained in end-of-life care. Diminishing the intensity of grief by stating that everything happens for a reason. This does not acknowledge the client’s spiritual pain or encourage verbalization. Question 26 of 28 According to The Joint Commission, when is an occurrence considered a sentinel event?(Select all that apply. One, some, or all options may be correct. Select all that apply A client’s outcome is death. A sentinel event is an unexpected outcome involving a death. There is permanent harm to a client. A sentinel event is an unexpected outcome involving permanent loss of function not related to the natural course of the client's illness. Severe temporary harm occurs to a client. A sentinel event is a serious physical or psychological injury. There is a suicide of a client receiving care in the facility. Suicide is a sentinel event. A client’s personal belonging are stolen from the room. Belongings stolen from the client’s room is not a sentinel event. Question 27 of 28 The unit’s manager contacts the hospital’s risk management team to notify them of the circumstances surrounding the client's death. The manager is advised to schedule a meeting with all stakeholders involved to initiate a root cause analysis (RCA).Which explanation is accurate in describing the purpose of the RCA? The sole purpose of an RCA is to analyze nursing practices, processes, and systems. Although an RCA analyzes nursing practice, processes, and systems it does so for the purpose of identifying areas of risk. The purpose of an RCA is to identify nursing areas that are at risk for sentinel events. A thorough analysis involves identifying the factors that are directly related to the sentinel event, analysis of the underlying processes and systems, identification of areas of risk that could potentially contribute to the sentinel event, and assignment of responsibility for implementation of necessary improvements. Tomey, A. M. (032008). Guide to Nursing Management and Leadership, 8th Edition.Mosby Elsevier; St. Louis, Missouiri. P483. The purpose of an RCA is to find out which staff members are at fault. The RCA is not a fault-finding mission. It analyzes at-risk areas for process improvement. Risk Management conducts an RCA to ensure that clients are billed accurately to pay for their hospital stay. Risk Management involves the development and implementation of strategies to prevent client injury, minimize financial loss, and preserve agency assets. Question 28 of 28 The nurse knows that a peer review process is a nonpunitive, collegial review of a nurse’s performance that is meant to improve nursing practice. What does the nurse anticipate will occur during the peer review process?(Select all that apply. One, some, or all options may be correct.) Select all that apply The peer review committee will evaluate the nurse’s care based on policy and standards of care. Peer review is a process in which a nurse’s professional performance is evaluated by a group of practicing nurses. . . The peer review committee will identify the need of knowledge deficiencies in the nurse’s practice. It provides a forum for sharing ideas, comparing the consistency of the staff members’ performance with standards, recognizing outstanding performance, and identifying areas in which further development is required. Tomey, A. M. (032008). Guide to Nursing Management and Leadership, 8th Edition. Mosby Elsevier; St Louis, Missour.p342. The peer review committee will conduct a yearly evaluation based on the nurse’s performance. Nurses’ practice is evaluated yearly in relation to professional practice standards, employers’ guidelines, and accrediting bodies’ statutes and regulations. The peer review committee will decide the appropriate disciplinary outcome for the nurse’s actions. The peer review committee will refer the nurse to the state board of nurses for disciplinary actions. The peer review committee will secure legal counsel for defense to the nurse and facility. The peer review committee does not secure legal counsel for defense of the nurse or the facility.