Which of the following actions is the best example of a nurse exercising nursing authority?
1. Assigning team responsibilities to individual team members
2. Evaluating a team member's ability to perform a bladder scan
3. Readjusting a client's turning schedule to provide hourly repositioning
4. Determining that a client will not be ambulated based on assessment findings
ANS: 4
Authority refers to legitimate power to give commands and make final decisions specific to a given position. Canceling a client's ambulation is the best example because it shows critical thinking in determining the appropriateness of an intervention. The remaining options are better examples of nursing responsibility.
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During the health assessment, the nurse notes that the patient has dry, dull, brittle hair and dry, flaky skin with poor turgor. What might this indicate?
A) Excessive physical activity B) Poor personal hygiene C) Poor nutritional status D) Damage from an environmental cause
A client diagnosed with mitral insufficiency has a murmur with a musical quality over the apex of the heart. The nurse recognizes that this is caused by:
1. Regurgitation of blood from the left ventricle into the left atrium. 2. Regurgitation of blood from the right ventricle into the right atrium. 3. Enlargement of the right ventricle due to increased pressure in the right atrium. 4. Regurgitation of blood from the aorta into the left ventricle.
The nurse encounters resistance during urinary catheterization of a male client. Which should the nurse implement first?
1. Hold catheter against sphincter. 2. Ask the client to inhale quickly. 3. Apply force to insert the catheter. 4. Remove the catheter immediately.
Which of the following questions would be most important for the nurse to ask then assessing a child with enuresis?
a. What are the child's and family's feelings toward enuresis? b. Is there a history of constipation or bowel movements that were large or painful? c. Is there a family history of enuresis or encopresis in the last two generations? d. At what age did you toilet-train the child, and how did the toilet training go?