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 caring for a client who is immobilized. Which of the following interventions is appropriate to prevent contracture?
- A. Position a pillow under the client's knees.
- B. Place a towel roll under the client's neck.
- C. Align a trochanter wedge between the client's legs.
- D. Apply an orthotic to the client's foot.
Correct Answer: D
Rationale: The correct answer is D: Apply an orthotic to the client's foot. Contractures are a common complication in immobilized clients, where muscles and tendons shorten and tighten due to lack of movement. Applying an orthotic to the foot helps maintain proper alignment and prevents the foot from being in a fixed position, thus reducing the risk of contractures. Positioning a pillow under the client's knees (A) may help with comfort but does not directly prevent contractures. Placing a towel roll under the client's neck (B) is unrelated to preventing contractures in the lower extremities. Aligning a trochanter wedge between the client's legs (C) is more for hip alignment and may not directly prevent contractures in the foot.
A nurse is caring for a client who is experiencing expressive aphasia and right hemiparesis following a stroke. Which of the following actions by the nurse best promotes communication among staff caring for the client?
- A. Posting swallowing precautions at the head of the client's bed.
- B. Noting changes in the treatment plan in the client's medical record.
- C. Recording the client's progress in the nurses' notes.
- D. Having interdisciplinary team meetings for the client on a regular basis.
Correct Answer: D
Rationale: The correct answer is D: Having interdisciplinary team meetings for the client on a regular basis. This promotes communication among staff by ensuring that all team members involved in the client's care are updated on the client's condition, progress, and treatment plan. It allows for collaboration and coordination of care, leading to better outcomes for the client. Posting swallowing precautions (A) only addresses one aspect of care and does not promote overall communication among staff. Noting changes in the treatment plan (B) and recording progress in nurses' notes (C) are essential but do not facilitate direct communication among staff. Interdisciplinary team meetings (D) involve direct communication, discussion, and collaboration among team members, making it the best option.
A nurse in a provider's office is caring for a client who asks about using acupuncture to manage his osteoarthritis pain. The nurse should identify which of the following conditions as a contraindication for receiving this treatment?
- A. Hypertension
- B. Obesity
- C. Hypothyroidism
- D. Herpes zoster
Correct Answer: D
Rationale: The correct answer is D: Herpes zoster. Acupuncture involves inserting needles into specific points on the body to alleviate pain. Herpes zoster, also known as shingles, is a viral infection that causes a painful rash. The presence of open sores or active infection in the area where acupuncture needles would be inserted can lead to complications such as spreading the virus or causing pain. Therefore, it is contraindicated to receive acupuncture treatment when a client has active herpes zoster.
Hypertension (A), obesity (B), and hypothyroidism (C) are not contraindications for acupuncture treatment. Hypertension may actually benefit from acupuncture as it can help reduce stress and improve circulation. Obesity and hypothyroidism do not pose any direct risks for receiving acupuncture treatment.
A nurse is caring for a client who requires nasotracheal suctioning. Identify the sequence the nurse should follow to perform suctioning.
- A. Rinse the catheter to remove secretions.
- B. Insert the catheter during the client's inspiration.
- C. Turn on the suction and set the pressure.
- D. Don sterile gloves
- E. Apply sunction while rotating catheter
Correct Answer: D,C,B,E,A
Rationale: Correct Order: D, C, B, E, A
Rationale:
1. Don sterile gloves (D): Ensures infection control and prevents cross-contamination.
2. Turn on suction and set pressure (C): Prepares equipment and ensures proper functioning.
3. Insert catheter during client's inspiration (B): Reduces risk of inducing hypoxia.
4. Apply suction while rotating catheter (E): Maximizes removal of secretions.
5. Rinse catheter to remove secretions (A): Ensures cleanliness and prevents re-introduction of secretions.
Summary of Incorrect Choices:
- F and G are not applicable in this sequence.
- Inserting the catheter during inspiration (B) is correct, not during expiration.
- Rinsing the catheter (A) is done after suctioning, not before.
A nurse is planning to reposition a client who had a stroke. Which of the following actions should the nurse take?
- A. Evaluate the client's ability to help with repositioning.
- B. Reposition the client without the use of assistive devices.
- C. Raise the side rails on both sides of the client's bed during repositioning.
- D. Discuss the client's preferences for determining a repositioning schedule.
Correct Answer: A
Rationale: The correct answer is A: Evaluate the client's ability to help with repositioning. This is essential as it considers the client's level of participation and promotes independence. Assessing the client's ability to assist ensures safety and prevents injury during repositioning. It also promotes client-centered care by involving the client in their own care.
Choice B is incorrect because repositioning without assistive devices may not be safe or effective, especially for a stroke client who may have limited mobility.
Choice C is incorrect because raising the side rails does not address the client's ability to help with repositioning. It may provide some safety measures but does not actively involve the client in the process.
Choice D is incorrect as discussing preferences for a repositioning schedule does not address the immediate need to evaluate the client's ability to assist with repositioning.
Overall, choice A is the most appropriate as it prioritizes the client's safety, independence, and active participation in their care.