NR-222 Health and Wellness - Set 2 - Part 2

Correct Answer: Report as required and tell the client why

Legally mandated disclosure overrides confidentiality, and the nurse discloses only what the law requires to the required recipient. Telling the client what must be reported keeps the relationship honest instead of ambushing her. Option b is incorrect because privacy has never been absolute. Reportable communicable disease, suspected abuse, and credible threats to others all create legal duties that sit above the duty of nondisclosure. Option c is incorrect because a mandated report does not wait for permission. Consent is not an element of the obligation, and delaying while the client decides leaves her exposed to the same person. Option d is incorrect because questioning the suspected abuser turns the nurse into an investigator and can escalate danger for the client. Reasonable suspicion is enough; verifying the story is somebody else's job.

Correct Answer: The narrowest applicable boundary governs her practice

A nurse practices inside the intersection of the practice act, employer policy, and her own demonstrated competence. Policy may narrow what the state permits, and where it does, the narrower limit is the one that binds. Option a is incorrect because that rule runs the other direction. A statute sets an outer limit that an employer may tighten, and doing the procedure anyway would be grounds for termination. Option b is incorrect because scope is not a menu. Picking whichever rule is most convenient in the moment abandons the whole point of having boundaries, and the more restrictive one always applies. Option c is incorrect because skill is only one of three limits. A nurse may be thoroughly competent at something her workplace still forbids, and competence cannot unlock what law or policy has closed.

Correct Answer: Witnessing attests that the signature is genuine

Signing as a witness attests that the person is who she claims to be, signed voluntarily, and that the signature is genuine. It does not certify that the provider's explanation was complete. Option b is incorrect because adequacy of the explanation is the responsibility of the clinician who performed it. A witness has no way to vouch for a conversation she was not part of. Option c is incorrect because that duty stays with the provider doing the procedure and cannot be shifted. Nursing reinforces, clarifies, checks understanding, and calls the provider back when something is missing. Option d is incorrect because acceptance of risk belongs to the client and lives in the consent conversation itself. A witness signature says nothing about what the client weighed or agreed to bear.

Correct Answer: Beneficence, taking positive action to benefit others

Beneficence requires an active step that produces benefit, and helping the colleague means the newly admitted client is seen sooner. The benefit reaches a client outside the nurse's own assignment, which the principle allows. Option a is incorrect because justice concerns fair distribution when resources are limited and choices must be made between clients. Nobody is being rationed here; one nurse simply has time and gives it. Option c is incorrect because veracity is about truthfulness, and the stem contains no exchange of information that could be true or false. Offering hands is a deed, not a disclosure. Option d is incorrect because autonomy in nursing ethics refers to a client's right to decide about his or her own care. A coworker's workload is not a self-determination question at all.

Correct Answer: Tell the client a free interpreter is available

Federal rules require that the client be told a qualified interpreter is available at no charge before anyone considers using a relative, so informing the client comes before any decision about who interprets. Option a is incorrect because speed is not an exception to the rule. Relatives summarize, soften, and leave out frightening words, and the consent discussion is exactly where an omission does the most damage. Option b is incorrect because partial interpreting still leaves the client relying on an untrained family member for the hardest content. Splitting the conversation creates gaps in the record and does not make the son qualified. Option d is incorrect because delaying a scheduled procedure to wait for relatives treats interpreting as a family duty. Qualified interpreters are available by phone or video within minutes, so nothing about this consent needs to wait.

Correct Answer: "I worked with that group, so I know them."

Claiming to know a group from past experience swaps the individual for a profile and closes the learning down. Humility keeps the nurse asking, because every client varies from whatever the group is said to believe. Option a is incorrect because asking the family directly is the behavior the teaching aims to produce. Nothing about that statement needs correction, so it would not be the response the charge nurse flags. Option b is incorrect because curiosity about one's own assumptions is self critique, the element humility is built on. A nurse examining her own lens is doing precisely what the concept requires of her. Option c is incorrect because inviting a family to revise the plan hands them real influence over the care. That shift in who decides is how power imbalance gets addressed at the bedside.

Correct Answer: Enculturation into her own culture

Learning one's own traditions from family is enculturation, and it moves inward rather than across cultures. No new or host culture appears anywhere in this scene, which rules out the other processes. Option b is incorrect because acculturation requires contact with a different society and the addition of its traits. The child is picking up her own heritage, not blending a second set of customs into it. Option c is incorrect because assimilation means a person stops preferring the culture they came from. Nothing here is being dropped, and the whole point of the visits is to pass traditions forward. Option d is incorrect because relativism describes a stance toward someone else's practices, not the transmission of a family's own. It belongs to how outsiders interpret behavior, which no one in this example is doing.

Correct Answer: Paternalism that overrides the client's autonomy

Paternalism is what beneficence becomes once it stops respecting a capable client's choice. Taking the shoes substitutes the nurse's judgment for his, and it also raises a false imprisonment concern. Option a is incorrect because doing good stops being defensible the moment it runs over a capable person's decision. This client understands the risk and has chosen to accept it. Option c is incorrect because a legitimate safety measure does not confine someone who has the right to get up. Removing footwear to trap a client in bed functions as a restraint, not a precaution. Option d is incorrect because acting on a client's behalf means securing what he has said he wants. Here the nurse works against his stated wish, which is the opposite of advocating for him.

Correct Answer: Provision 2, primary commitment to the client

Provision 2 states that the nurse's primary commitment is to the patient. Whenever an employer, a family member, or the nurse's own convenience competes with the client's interest, this provision settles the conflict. Option a is incorrect because that provision covers what the nurse owes herself, including rest, integrity, and continued competence. The conflict here sits between the employer's timeline and the client's safety. Option b is incorrect because advancing the profession through research, standards development, and policy work is a different arena entirely. Nothing in this scenario involves scholarship or the shaping of practice standards. Option d is incorrect because its subject is the profession of nursing acting through its organizations, not one nurse at a bedside. An individual dispute over a discharge does not reach that collective level.

Correct Answer: Advocacy shown through education the client understands

Education counts as a form of advocacy. A client who cannot read the instructions cannot act on them, so obtaining translation and a qualified interpreter secures his right to understand his own care. Option a is incorrect because charting what was given documents the event; it does not fix the barrier. The nurse's action changes what the client can actually do after he goes home. Option b is incorrect because handing over a printed sheet would have completed the assigned task. What the nurse did went past the assignment to protect a right the client would otherwise lose. Option c is incorrect because translating a document for the person it belongs to raises no disclosure issue. Sharing information with the client himself is always permitted and is never a privacy concern.

Correct Answer: Hold transport and notify the surgeon

Consent from a client who does not understand is not consent. The nurse stops the process and calls the person who owes the disclosure, because only the surgeon can complete an explanation of the procedure. Option a is incorrect because the duty of disclosure belongs to the provider performing the operation and cannot be handed to nursing. A nurse may reinforce and clarify, but she does not supply the original explanation. Option b is incorrect because soothing words leave the misunderstanding untouched and send the client to an operating room anyway. Proceeding on invalid consent can amount to battery once the first incision is made. Option d is incorrect because a second signature on the same uninformed decision adds paper, not understanding. The form documents a conversation; it cannot manufacture one that never took place.

Correct Answer: Justice, since allocation follows uniform clinical criteria

When one client's demand meets a scarce resource, consistently applied allocation criteria outrank individual preference. Distributing the bed by clinical need rather than by who asks loudest is distributive justice. Option b is incorrect because self-determination covers what happens to a client's own body, not a claim on a resource someone else needs more. Preference does not create an entitlement to a bed. Option c is incorrect because nobody promised this client the bed. Faithfulness would be in play only if a commitment had been made and the charge nurse were now walking it back. Option d is incorrect because honesty about the criteria is a side detail rather than the reason the decision is right. What settles the case is how the limited bed gets assigned.

Correct Answer: Assimilation into the host culture

When the culture of origin is no longer preferred and its markers have fallen away, no identifiable minority culture remains. That substitution of one culture for another is exactly what assimilation names. Option a is incorrect because retention is the deciding word, and this client retained nothing. Acculturation would show him keeping his language or holidays alongside the new customs he picked up. Option b is incorrect because his parents taught him a culture he has since set aside. Enculturation describes that earlier childhood learning, not the later shift away from it in a new country. Option c is incorrect because cultural blindness is a professional failing, not a life course. A nurse who insists that differences do not exist shows it, and this client is simply describing his own history.

Correct Answer: The RN remains accountable for the client outcome

Delegation hands over a task and the responsibility for performing it, but never the accountability for the result. The RN who delegates must verify and interpret the data, and she answers for what follows. Option a is incorrect because that is the single most tested misconception in this content. Handing off the doing of a task never hands off answerability for how the client turns out. Option c is incorrect because unlicensed staff carry no professional license and therefore no professional liability of that kind. They answer for performing the task as taught, within a scope the RN supervises. Option d is incorrect because answerability does not move with a pen. Charting a number someone else obtained without checking it is itself a failure the delegating nurse will have to explain.

Correct Answer: It leaves care relevant differences unassessed

Refusing to notice difference sounds fair but stops the nurse from asking about fasting obligations, modesty needs, or language needs. What goes unasked goes unmet, and disparities widen from there. Option a is incorrect because the problem runs the other way. Her approach shrinks difference to nothing, and the concern is that real variation in beliefs and practices disappears from the assessment. Option b is incorrect because clients are given no additional say at all under this approach. Uniform treatment decided in advance by the nurse narrows client choice rather than expanding it. Option d is incorrect because staffing numbers have nothing to do with the flaw. Asking a client what matters to her costs a few minutes of one nurse's time, not another person on the schedule.

Correct Answer: "Interpreting requires assessed proficiency, so I will call services."

Organizations must verify the competence of anyone providing language assistance. Growing up with a language is not the same as assessed proficiency, medical vocabulary, and training in interpreting technique, so the nurse calls interpreter services. Option a is incorrect because convenience never establishes qualification. An unassessed staff member may misname a device, a dose, or a symptom, and inhaler teaching depends on precise wording the client can act on. Option c is incorrect because the nurse cannot check wording in a language she does not speak. Supervision that depends on catching an error you cannot hear offers the client no protection at all. Option d is incorrect because charting an unqualified interpretation records a problem rather than solving one. Documentation is meant to show that meaningful access was provided, and this note would show the opposite.

Correct Answer: Nonmaleficence, because the aim is preventing harm

The same action can be framed either way, and the framing decides the answer. Charting that turning prevents a pressure injury describes avoiding foreseeable harm, which is the territory of nonmaleficence. Option a is incorrect because that label fits the first nurse, whose note emphasizes comfort and circulation. Beneficence answers what will make a client better off, and this note answers what could injure one. Option b is incorrect because justice would be at stake only if one client were turned and another neglected on the basis of insurance, behavior, or status. Both are being repositioned. Option c is incorrect because nothing in the scenario describes a promise given to a client. A unit routine is not a commitment the nurse personally made, so faithfulness never enters the analysis.

Correct Answer: Culture shock in an unfamiliar system

Disorientation, anxiety, and apparent resistance in someone immersed in unfamiliar routines describe culture shock. What looks like refusal is often bewilderment at rules and expectations she has never encountered. Option b is incorrect because ethnocentrism means judging another culture from inside your own preconceptions. The client is not evaluating anyone; she is frightened by a setting whose rules she cannot read. Option c is incorrect because assimilation would show a person who has already taken on the host culture and let go of the original. This client has just arrived and has taken on nothing yet. Option d is incorrect because cultural blindness is something clinicians do, not clients. It names a caregiver who denies that differences matter, which does not fit a frightened newcomer at all.

Correct Answer: Full care including pain control and antibiotics

The order applies only to cardiopulmonary arrest. Everything else continues, so pain control, antibiotics, oxygen, nutrition, positioning, and wound care remain part of the plan unless separately limited by another order. Option a is incorrect because comfort-focused care is a separate decision that requires its own conversation and orders. Assuming it follows automatically from a resuscitation order strips the client of treatment he is still entitled to. Option b is incorrect because a valid order already reflects a discussion with the client or surrogate. Pausing ordinary nursing care while relatives are consulted would be neglect dressed up as caution. Option d is incorrect because monitoring numbers without treating anything abandons the person attached to them. A client who is not to receive chest compressions still needs turning, hygiene, medication, and every other indicated intervention.

Correct Answer: Ethnocentrism using her own standard

Her own preference is serving as the yardstick for good care, which is what makes the statement ethnocentric. Congruent care asks what this client wants rather than substituting what the nurse would want. Option a is incorrect because beneficence means acting in the client's interest, and the client's interest has not been asked about here. Good intentions aimed at the wrong target still miss the person. Option c is incorrect because advocacy means speaking up for what the client has said they want. This nurse has not learned what any client wants, so there is nothing yet for her to advance. Option d is incorrect because humility begins with recognizing that the nurse's own values are one set among many. The statement does the reverse and makes those values the universal measure of good care.