Dr.

Mohammed Osman Yahiya

PhD. Community Health Nursing

Question 3
An antihypertensive medication has been prescribed for a client with hypertension. The client
tells the clinic nurse that they would like to take an herbal substance to help lower their blood
pressure. The nurse should take which action?
a. Tell the client that herbal substances are not safe and should never be used.
b. Teach the client how to take their blood pressure so that it can be monitored closely.
c. Encourage the client to discuss the use of an herbal substance with the health care provider.
d. Tell the client that if they take the herbal substance they will need to have their blood
pressure checked frequently.
Rationale:
- Although herbal substances may have some beneficial effects, not all herbs are safe to use.
- Clients who are being treated with conventional medication therapy should be encouraged
to avoid herbal substances with similar pharmacological effects because the combination
may lead to an excessive reaction or to unknown interaction effects.
- The nurse should advise the client to discuss the use of the herbal substance with the HCP.
Question 4
The nurse hears a client calling out for help, hurries down the hallway to the client’s room, and
finds the client lying on the floor. The nurse performs an assessment, assists the client back to
bed, notifies the health care provider of the incident, and completes an incident report. Which
statement should the nurse document on the incident report?
a. The client fell out of bed.
b. The client climbed over the side rails.
c. The client was found lying on the floor.
d. The client became restless and tried to get out of bed.
Rationale:
- The report should contain a factual description of the incident, any injuries experienced by
those involved, and the outcome of the situation.
- The correct option is the only one that describes the facts as observed by the nurse.
- Options a, b, and d are interpretations of the situation and are not factual information as
observed by the nurse.

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 Dr. Mohammed Osman Yahiya
PhD. Community Health Nursing

Question 5
A client is brought to the emergency department by emergency medical services (EMS) after
being hit by a car. The name of the client is unknown, and the client has sustained a severe head
injury and multiple fractures and is unconscious. An emergency craniotomy is required.
Regarding informed consent for the surgical procedure, which is the best action?
a. Obtain a court order for the surgical procedure.
b. Ask the EMS team to sign the informed consent.
c. Transport the victim to the operating room for surgery.
d. Call the police to identify the client and locate the family.
Rationale:
- In general, there are two situations in which informed consent of an adult client is not
needed.
• One is when an emergency is present and delaying treatment for the purpose
of obtaining informed consent would result in injury or death to the client.
• The second is when the client waives the right to give informed consent.
- Option (a) will delay emergency treatment
- And option (b) is inappropriate.
- Although option (d) may be pursued, it is not the best action.
Question 6
The nurse has just assisted a client back to bed after a fall. The nurse and health care provider
have assessed the client and have determined that the client is not injured. After completing the
incident report, the nurse should implement which action next?
a. Reassess the client.
b. Conduct a staff meeting to describe the fall.
c. Document in the nurse’s notes that an incident report was completed.
d. Contact the nursing supervisor to update information regarding the fall.
Rationale:
- After a client’s fall, the nurse must frequently reassess the client because potential
complications do not always appear immediately after the fall.
- The client’s fall should be treated as private information.
- An incident report is a problem-solving document; however, its completion is not
documented in the nurse’s notes.
- If the nursing supervisor has been made aware of the incident, the supervisor will contact
the nurse if status update is necessary.

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