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 is 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 and force-feeding them constitutes a threat of harm, which is considered assault. This is inappropriate behavior and violates the client's autonomy. Battery (choice A) involves actual harmful or offensive contact, which is not present in this situation. Negligence (choice C) refers to a failure to exercise reasonable care, which is not applicable here. Malpractice (choice D) involves professional negligence or misconduct, which is also not relevant in this context.
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A nurse is providing discharge teaching to the partner of a client who has a tracheostomy. Which of the following information should the nurse include in the teaching?
- A. How to operate the portable suction machine.
- B. How to secure the tracheostomy tube with ties at the back of the neck.
- C. How to change the nondisposable tracheostomy tube daily.
- D. How to change the tracheostomy dressing using clean technique.
Correct Answer: D
Rationale: The correct answer is D: How to change the tracheostomy dressing using clean technique. This is important to prevent infection and promote healing. First, wash hands thoroughly to maintain cleanliness. Second, gather necessary supplies such as clean gloves, sterile gauze, and saline solution. Third, remove the old dressing carefully and inspect the stoma for any signs of infection or irritation. Fourth, clean around the stoma with saline solution and gently pat dry. Finally, apply a new, sterile dressing using clean technique to maintain a clean and dry environment. Choice A is incorrect because operating a suction machine is typically done by healthcare professionals. Choice B is incorrect as securing the tracheostomy tube is usually done by healthcare providers to ensure proper placement. Choice C is incorrect as changing the tracheostomy tube daily is not a standard practice unless specifically indicated by a healthcare provider.
A nurse is caring for a client who is expressing anger about his diagnosis of colorectal cancer. Which of the following actions should the nurse take?
- A. Discuss the risk factors for colon cancer.
- B. Focus teaching on what the client will need to do in the future to manage his illness.
- C. Provide the client with written information about the phases of loss and grief.
- D. Reassure the client that this is an expected response to grief.
Correct Answer: D
Rationale: The correct answer is D: Reassure the client that this is an expected response to grief. This is the correct action as it validates the client's feelings and provides reassurance that anger is a common emotion when dealing with a cancer diagnosis. By acknowledging the client's emotions, the nurse can build trust and support the client through the grieving process.
A: Discussing risk factors is not the priority when the client is expressing anger.
B: Focusing on future management may be overwhelming for the client at this stage.
C: Providing written information about loss and grief phases may not address the client's current emotional state.
In summary, option D is the best choice as it acknowledges the client's feelings and offers support during a difficult time.
A nurse is caring for a client who has given informed consent for electroconvulsive therapy. Just before the procedure, the client tells the nurse she is considering not going forward with the treatment. Which of the following statements by the nurse is appropriate?
- A. Most people who have this procedure feel better following the treatment.'
- B. Your doctor wouldn't have ordered this treatment unless it was necessary.'
- C. It's okay to be nervous before this treatment.'
- D. You don't have to go through with the treatment.'
Correct Answer: D
Rationale: Correct Answer: D. "You don't have to go through with the treatment."
Rationale: This response respects the client's autonomy and right to make decisions about their own healthcare. It acknowledges the client's change of mind and supports their decision-making process without pressuring them. It is important for healthcare providers to prioritize patient autonomy and respect their choices.
Other Choices:
A: Incorrect. This statement may invalidate the client's feelings and pressure them to proceed with the treatment.
B: Incorrect. This statement undermines the client's autonomy by implying that the doctor's decision is more important than the client's own preferences.
C: Incorrect. While acknowledging nervousness is appropriate, it does not address the client's change of mind and decision to not proceed with the treatment.
A nurse is conducting health promotion education regarding contraindications to combination oral contraceptive use to a group of women. Which of the following conditions should the nurse include in the teaching?
- A. Hypertension
- B. Fibromyalgia
- C. Renal calculi
- D. Fibrocystic breast disease.
Correct Answer: A
Rationale: The correct answer is A: Hypertension. Hypertension is a contraindication to combination oral contraceptive use due to the increased risk of cardiovascular events. The estrogen component in oral contraceptives can further elevate blood pressure, leading to complications. Other choices like B: Fibromyalgia, C: Renal calculi, and D: Fibrocystic breast disease are not contraindications for oral contraceptive use. Fibromyalgia is a chronic pain condition unrelated to oral contraceptives. Renal calculi are kidney stones, which do not directly affect the safety of oral contraceptives. Fibrocystic breast disease is a benign condition and not a contraindication to oral contraceptives.
A nurse is preparing to insert an IV catheter for a client. Which of the following actions should the nurse plan to take?
- A. Choose a vein that is palpable and straight.
- B. Elevate the client's arm prior to insertion.
- C. Apply a tourniquet below the venipuncture site.
- D. Select a site on the client's dominant arm.
Correct Answer: A
Rationale: Correct Answer: A. Choose a vein that is palpable and straight.
Rationale: Selecting a palpable and straight vein ensures successful insertion and reduces the risk of complications like infiltration or phlebitis. A straight vein allows for easier catheter insertion and reduces the chance of vein damage. Palpability helps in accurately locating the vein for successful cannulation.
Summary of Other Choices:
B: Elevating the client's arm may help distend the veins, but it is not a necessary step for IV catheter insertion.
C: Applying a tourniquet below the venipuncture site can help visualize veins better but is not crucial for successful IV catheter insertion.
D: Selecting the site on the client's dominant arm is not necessary. The nurse should choose the best vein regardless of the arm dominance to ensure successful cannulation.