Nokea
A nurse is caring for a client who is confused and uncooperative. The client hit the nurse when she attempted to give him his medication. The nurse asks the charge nurse if she can restrain the client. The charge nurse should tell the nurse this action is a violation of the client's rights and is an example of which of the following?
- A. Defamation of character
- B. Slander
- C. False imprisonment
- D. Invasion of privacy
Correct Answer: C
Rationale: Correct Answer: C. False imprisonment
Rationale:
1. False imprisonment is the intentional restriction of a person's freedom of movement without justification.
2. Restraining the client against their will without a valid reason is a violation of their rights.
3. The client has the right to refuse treatment, and restraining them would be considered false imprisonment.
4. Defamation of character (A) and slander (B) involve damaging one's reputation through false statements.
5. Invasion of privacy (D) pertains to intrusion into a person's private affairs, not physical restraint.
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A nurse notes a provider frequently arrives to the unit with bloodshot eyes and smells like alcohol after lunch. Which of the following actions should the nurse take?
- A. Inform the state medical board for an immediate investigation.
- B. Counsel the provider to determine the cause of the substance abuse.
- C. Notify the nursing supervisor of the concerns.
- D. Encourage clients to change to a different provider.
Correct Answer: C
Rationale: The correct answer is C: Notify the nursing supervisor of the concerns. This is the most appropriate action because it allows for immediate intervention by someone in authority to address the provider's behavior. The nursing supervisor is in a position to assess the situation, determine the appropriate course of action, and provide support to the nurse in dealing with this sensitive issue. Reporting to the state medical board (choice A) may be premature and could potentially harm the provider's career without first addressing the issue internally. Counseling the provider (choice B) may not be effective if there is a serious substance abuse problem. Encouraging clients to change providers (choice D) is not the nurse's responsibility and may not address the root cause of the issue.
A nurse is caring for a client who is refusing a blood transfusion due to religious beliefs. Which of the following actions should the nurse take?
- A. Administer the transfusion after obtaining a court order.
- B. Document the client's refusal and inform the provider.
- C. Convince the client to accept the transfusion for their health.
- D. Ask the client's family to persuade the client.
Correct Answer: B
Rationale: Documenting the refusal and informing the provider respects the client's autonomy and ensures appropriate follow-up, while adhering to ethical and legal standards.
A nurse is caring for a group of clients. The nurse demonstrates adherence to the ethical principle of fidelity by doing which of the following?
- A. Keeping an appointment with a client
- B. Allowing a new mother to hold her stillborn infant
- C. Confirming that a client going for surgery has signed a consent form
- D. Refusing to disclose information about a client to the media
Correct Answer: A
Rationale: The correct answer is A: Keeping an appointment with a client. Fidelity in nursing ethics refers to the nurse's obligation to be faithful and keep promises made to clients. By keeping an appointment with a client, the nurse is demonstrating reliability and honoring their commitment, which is essential for building trust and maintaining the therapeutic relationship. Choices B, C, and D do not directly relate to fidelity. Allowing a mother to hold her stillborn infant (B) is an example of compassion and emotional support, confirming a client's surgery consent form (C) is related to autonomy and informed consent, and refusing to disclose client information to the media (D) is about confidentiality and privacy, not fidelity.
A volunteer assigned to the pediatric unit reports to the charge nurse for an assignment. Which of the following assignments is unsafe for the volunteer?
- A. Transporting a school-age client who is in traction to another department
- B. Reading a book to a preschool client who has AIDS
- C. Rocking an infant who was admitted for croup
- D. Playing a computer video game with an adolescent who has sickle cell disease
Correct Answer: A
Rationale: The correct answer is A because transporting a school-age client in traction requires specialized training to ensure proper handling and safety precautions. Traction devices are delicate and any mishandling could lead to injury. Reading a book to a preschool client with AIDS (B) promotes emotional support. Rocking an infant with croup (C) provides comfort. Playing a computer video game with an adolescent with sickle cell disease (D) promotes social interaction and distracts from pain.
A nurse is planning to assign tasks for a group of clients. Which of the following tasks should the nurse plan to assign to an assistive personnel (AP)? (Select all that apply.)
- A. Ambulate an older adult client who has hypertension.
- B. Provide discharge instructions for a client who has a new skin graft.
- C. Check a blood product with another nurse prior to administration.
- D. Weigh a client who has heart failure.
- E. Perform an admission assessment on a client.
Correct Answer: A,D
Rationale: The correct tasks to assign to an assistive personnel (AP) are A and D. APs are trained to assist with basic care activities. Ambulating an older adult client with hypertension and weighing a client with heart failure are within the scope of practice for APs as they do not involve complex assessments or critical decision-making. Providing discharge instructions (B) requires specialized knowledge and education, which is beyond the scope of an AP. Checking a blood product (C) and performing an admission assessment (E) require specific training and expertise that only licensed nurses should perform.