Extract:

Question 1 of 5

Which of the following is NOT an essential component of a restraint order?

Correct Answer: A

Rationale: A restraint order requires the reason , type , and client behaviors necessitating the restraint . Informed consent is not typically required for restraints, as they are used in emergencies or for safety.

Question 2 of 5

The nurse is caring for a client with a history of burns. Which of the following psychosocial interventions should be included in the plan of care?

A. Encourage expression of feelings. B. Restrict family visits. C. Limit social interactions. D. Provide sedatives routinely.

Correct Answer: A

Rationale: Encouraging expression of feelings supports emotional coping in burn recovery.

Question 3 of 5

To improve the accuracy of client identification, the nurse must use at least two identifiers when providing care, treatment, or services. Which of the following are appropriate? Select all that apply.

A. Room number. B. Bed number. C. Medical record number. D. Name band. E. Social security number.

Correct Answer: C,D,E

Rationale: Appropriate identifiers include medical record number, name band, and social security number, as they are unique to the client. Room and bed numbers are not reliable identifiers.

Question 4 of 5

Which of the following should the nurse expect to include in the plan of care to ensure adequate nutrition for a very active, talkative, and easily distractible client who is unable to sit through meals?

A. Direct the client to his room to eat. B. Offer the client nutritious finger foods. C. Ask the client's family to bring his favorite foods from home. D. Ask the client about his food preferences.

Correct Answer: B

Rationale: Nutritious finger foods allow the client to eat while accommodating their distractibility and activity level.

Question 5 of 5

A new breast-feeding mother experiencing breast engorgement is provided with instructions regarding care for the condition. Which statement by the mother indicates to the nurse that she possesses an understanding of the measures that will provide comfort for the engorgement?

A. I will breast-feed using only one breast. B. I will apply cold compresses to my breasts. C. I will avoid the use of a bra while my breasts are engorged. D. I will massage my breasts before feeding to stimulate letdown.

Correct Answer: D

Rationale: Comfort measures for breast engorgement include massaging the breasts before feeding to stimulate letdown, alternating the breasts during feeding, taking a warm shower or applying warm compresses just before feeding, and wearing a supportive well-fitting bra at all times. None of the other options suggest correct measures.