PN MANAGEMENT ONLINE PRACTICE 2019 A
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PN MANAGEMENT ONLINE PRACTICE 2019 A
1.A nurse in an outpatient clinic is caring for a client who has schizophrenia. For which of the following client actions should the nurse recommend transfer to an acute care facility?
The client develops command hallucinations
• Command hallucinations involve hearing "voices" that direct the client to take specific actions. These actions can be directed at causing self-harm or injury to others. To provide for safety of the client and others, the nurse should recommend that the client be transferred to an acute care facility.
2.A nurse is using a critical pathway while providing care to a client who is 3 days postoperative. Which of the following events should the nurse document as a variance?
The client has a circular area of nonblanchable redness on her left heel
• A variance occurs when expected outcomes of the critical pathway are not met. The nurse should document that the client has a circular area of nonblanchable redness on her left heel as a variance because this indicates the initial stage of a pressure ulcer and is not an expected outcome.
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- Submitted On 01 Mar, 2022 03:01:06
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