Nokea
A nurse is caring for a client who repeatedly refuses meals. The nurse overhears an assistive personnel (AP) telling the client,If you don't eat I'll put restraints on your wrists and feed you." The nurse should intervene and explain to the AP that this statement constitutes which of the following torts?"
- A. Battery
- B. Assault
- C. Negligence
- D. Malpractice
Correct Answer: B
Rationale: The correct answer is B: Assault. Assault refers to the threat of harmful or offensive contact without the actual contact occurring. In this scenario, the AP's statement of putting restraints on the client constitutes a threat of physical harm, which falls under the definition of assault. The nurse should intervene to prevent any potential harm to the client. The other choices are incorrect because: A: Battery involves actual harmful or offensive contact, which has not occurred in this situation. C: Negligence refers to a failure to provide reasonable care, not a threat of harm. D: Malpractice involves professional negligence or misconduct, which is not demonstrated in this scenario.
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A charge, nurse is teaching new staff members about factors that increase a client's risk to become violent: Which of the following risk factors should the nurse include as the best predictor of future violence?
- A. A history of being in prison
- B. Male gender
- C. Experiencing delusions
- D. Previous violent behavior
Correct Answer: D
Rationale: The correct answer is D: Previous violent behavior. This is the best predictor of future violence because past behavior is a strong indicator of future actions. Individuals who have a history of violent behavior are more likely to engage in violent acts again. Choice A (A history of being in prison) is not as strong of a predictor as it does not specifically address violent behavior. Choice B (Male gender) is a generalization and not always indicative of violent behavior. Choice C (Experiencing delusions) may increase the risk of violence but does not directly predict future violent behavior as strongly as previous violent actions do.
Which of the following actions should the nurse take?
- A. Refer the adolescent to a local mental health clinic.
- B. Advise the adolescent to place the newborn for adoption
- C. Contact the adolescent's parent for assistance
- D. Assist the adolescent in applying for Medicaid
Correct Answer: D
Rationale: Medicaid can provide financial assistance for prenatal care and delivery.
Which of the following statements by a client indicates an understanding of the teaching?
- A. I should take antibiotics when I have a virus.
- B. I can visit my nephew who has chickenpox S days after the sores have crusted.
- C. I can clean my cat's litter box during my pregnancy.
- D. I should wish my hands for 10 seconds with hat water after working in the garden.
Correct Answer: B
Rationale: Chickenpox sores crust over before becoming non-contagious.
Which of the following findings should the nurse include in the teaching?
- A. Swelling of the face
- B. Bleeding gums
- C. Urinary frequency
- D. Faintness upon rising
Correct Answer: A
Rationale: Facial swelling may indicate preeclampsia requiring prompt evaluation.
A home health nurse is caring for a child who has Lyme disease. Which of the following is an appropriate action for the nurse to take
- A. Ensure the state health department has been notified
- B. Administer antitoxin.
- C. Educate the family to avoid sharing personal belongings
- D. Assess for skin necrosis
Correct Answer: A
Rationale: Correct Answer: A: Ensure the state health department has been notified.
Rationale:
1. Lyme disease is a reportable infectious disease, so notifying the state health department is crucial for tracking and controlling its spread.
2. Reporting to the health department allows for proper surveillance and monitoring of the disease in the community.
3. By notifying the health department, appropriate public health interventions can be implemented to prevent further cases.
Summary of Incorrect Choices:
B: Administer antitoxin - Lyme disease is caused by a bacterium, not a toxin, so antitoxin administration is not appropriate.
C: Educate the family to avoid sharing personal belongings - While important for hygiene, it does not directly address the management of Lyme disease.
D: Assess for skin necrosis - Skin necrosis is not a common manifestation of Lyme disease, so this action is not a priority in caring for a child with Lyme disease.