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The nurse is teaching an in-service on legal issues in nursing. Which situation is an example of battery, an intentional tort?
- A. The nurse threatens the client who is refusing to take a hypnotic medication.
- B. The nurse forcibly inserts a Foley catheter in a client who refused it.
- C. The nurse tells the client a nasogastric tube insertion is not painful.
- D. The nurse gives confidential information over the telephone.
Correct Answer: B
Rationale: Battery involves nonconsensual physical contact, like forcible catheter insertion. Threats (assault), misrepresentation (negligence), or confidentiality breaches are not battery.
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The nurse is obtaining the client’s signature on a surgical permit form. The nurse determines the client does not understand the surgical procedure and possible risks. Which action should the nurse take first?
- A. Notify the client's surgeon.
- B. Document the information in the chart.
- C. Contact the operating room staff.
- D. Explain the procedure to the client.
Correct Answer: A
Rationale: Notifying the surgeon ensures informed consent, as the surgeon must clarify risks and procedures. Documentation, OR contact, or nurse explanation is secondary.
The client diagnosed with chronic back pain is being placed on a transcutaneous electrical nerve stimulation (TENS) unit. Which information should the nurse teach?
- A. The TENS unit will deaden the nerve endings, and the client will not feel pain.
- B. The TENS unit could cause paralysis if the client gets the unit wet.
- C. The TENS unit stimulates the nerves in the area, blocking the pain sensation.
- D. The TENS unit should be left on for an hour, and then taken off for an hour.
Correct Answer: C
Rationale: TENS units stimulate nerves to block pain signals, per gate control theory. Deadening nerves, paralysis, or specific on/off cycles are inaccurate.
The male client who has made himself a do not resuscitate (DNR) order is in pain. The client's vital signs are P 88, R 8, and BP 108/70. Which intervention should be the nurse's priority action?
- A. Refuse to give the medication because it could kill the client.
- B. Administer the medication as ordered and assess for relief from pain.
- C. Wait until the client' respirations improve and then administer the medication.
- D. Notify the HCP the client is unstable and pain medication is being held.
Correct Answer: B
Rationale: Pain relief is a priority, even with DNR; administering medication as ordered with assessment is safe, despite low respirations. Refusing, delaying, or notifying HCP delays care.
The hospice care nurse is conducting a spiritual care assessment. Which statement is the scientific rationale for this intervention?
- A. The client will ask all of his or her spiritual questions and get answers.
- B. The nurse is able to explain to the client how death will affect the spirit.
- C. Spirituality provides a sense of meaning and purpose for many clients.
- D. The nurse is the expert when assisting the client with spiritual matters.
Correct Answer: C
Rationale: Spirituality offers meaning and purpose, supporting holistic hospice care. Clients may not ask all questions, nurses aren’t spiritual experts, and death’s spiritual impact is subjective.
The nurse is caring for the family of the client who has just died. Which is the nurse's priority action?
- A. Be with the family.
- B. Call the funeral home.
- C. Notify the minister.
- D. Fill out the death certificate.
Correct Answer: A
Rationale: Being with the family provides immediate emotional support, a nursing priority post-death. Funeral, minister, or certificate tasks are secondary.