Nokea
A nurse observes an AP reprimanding a client for not using the urinal properly. The AP tells him she will put a diaper on him if he does not use the urinal more carefully next time. Which of the following torts is the AP committing?
- A. "Assault"
- B. Battery
- C. False imprisonment
- D. Invasion of privacy
Correct Answer: A
Rationale: The correct answer is A: "Assault." Assault is the intentional act that creates fear of imminent harmful or offensive contact. In this scenario, the AP's threat of putting a diaper on the client if he does not use the urinal properly next time constitutes assault as it instills fear in the client. Choice B, Battery, involves actual harmful or offensive contact, which is not present here. Choice C, False Imprisonment, involves restricting someone's freedom of movement, which is not happening in this scenario. Choice D, Invasion of Privacy, is not applicable as the situation does not involve a violation of the client's privacy.
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A nurse is preparing to insert an NG tube for a client who requires gastric decompression. Which of the following actions should the nurse perform prior to beginning the procedure? Select all.
- A. Review a signal the client can use if feeling any distress.
- B. Lay a towel across the client's chest.
- C. Administer oral pain meds.
- D. Obtain a Dobhoff tube for insertion.
- E. Have a petroleum-based lubricant available.
Correct Answer: A, B
Rationale: Correct Answer: A, B
Rationale:
A: Review a signal the client can use if feeling any distress - This is important to ensure the client can communicate any discomfort or issues during the procedure.
B: Lay a towel across the client's chest - Helps protect the client's clothing and bedding from potential spillage during the procedure.
C: Administer oral pain meds - Not necessary prior to NG tube insertion for gastric decompression.
D: Obtain a Dobhoff tube for insertion - Dobhoff tube is not typically used for gastric decompression with NG tube.
E: Have a petroleum-based lubricant available - Lubricant is required for NG tube insertion but not specifically petroleum-based.
F:
G:
Summary: Choices C, D, and E are not necessary prior to beginning the NG tube insertion procedure. Choice A and B are essential steps to ensure patient safety and comfort during the process.
A nurse is teaching a client how to administer medication through a jejunostomy tube. Which of the following instructions should the nurse include in the teaching?
- A. Flush the tube before & after each med.
- B. Administer your meds w/your enteral feeding.
- C. Administer tablets through the tube slowly.
- D. Mix all the crushed meds prior to dissolving in water.
Correct Answer: A
Rationale: Rationale: Choice A is correct because flushing the jejunostomy tube before and after each medication helps prevent clogging and ensures proper delivery. Flushing clears the tube and ensures medication is fully administered. Choice B is incorrect as medications should not be administered with enteral feedings to prevent interactions. Choice C is incorrect as tablets should be crushed before administration. Choice D is incorrect as crushed medications should be dissolved one at a time to avoid interactions.
A nurse is teaching a client about taking multiple oral meds at home to include time-release capsules, liquid meds, enteric-coated pills, & narcotics. Which of the following statements by the client indicates an understanding of the teaching?
- A. I can open the capsule w/the beads in it & sprinkle them on my oatmeal.
- B. If I am having difficulty swallowing, I will add the liquid meds to a batch of pudding.
- C. The pills w/the coating on them can be crushed.
- D. I will eat 2 crackers w/the pain pills.
Correct Answer: D
Rationale: The correct answer is D: "I will eat 2 crackers with the pain pills." This statement indicates an understanding of the teaching because taking narcotics with food, such as crackers, can help reduce stomach upset and nausea commonly associated with these medications. This demonstrates the client's awareness of the importance of food intake when taking certain medications.
Choice A is incorrect because opening a time-release capsule and sprinkling the beads on food can alter the medication's intended release mechanism. Choice B is incorrect as mixing liquid meds with pudding may not ensure proper dosage or absorption. Choice C is incorrect as crushing enteric-coated pills can interfere with their delayed-release properties.
A nursing instructor is explaining the various stages of the lifespan to a group of nursing students. The nurse should offer which of the following behaviors by a young adult as an example of appropriate psychosocial development?
- A. Becoming actively involved in providing guidance to the next generation
- B. Adjusting to major changes in roles and relationships due to losses
- C. Devoting a great deal of time to establishing an occupation
- D. Finding oneself 'sandwiched' in between & being responsible for two generations
Correct Answer: C
Rationale: The correct answer is C: Devoting a great deal of time to establishing an occupation. This is an example of appropriate psychosocial development for a young adult as per Erikson's theory of psychosocial development. During the stage of young adulthood, individuals focus on establishing their careers and personal identities. This is a crucial developmental task during this stage, as it helps individuals gain a sense of purpose and direction in life. Choices A, B, and D involve responsibilities and challenges more commonly associated with other stages of life, such as middle adulthood or late adulthood. Therefore, they are not appropriate examples of psychosocial development for a young adult.
The skin barrier covering a client's intestinal fistula keeps falling off when she stands up to ambulate. The nurse has reapplied it twice during the shift, but it remains intact only when the client is supine in bed. The nurse telephoned the physical therapist about the difficulties containing the drainage from the fistula, so the therapist didn't ambulate the client today. The client sat in a chair during lunch w/an absorbent pad over the fistula. The client ate all the food on her tray. The wound care nurse confirmed that she will see the client later today. The client states she feels frustrated at not having physical therapy, but the nurse thinks the client welcomed having a day to rest. Which of the following information should the nurse include in the change-of-shift report? Select all.
- A. The physical therapist didn't ambulate the client today
- B. The skin barrier's seal stays on in bed but loosens when the client stands.
- C. The client seemed to welcome having a 'day off' from physical therapy
- D. The wound care nurse will see the client later today
- E. The client ate all the food on her lunch tray
Correct Answer: A, B, D
Rationale: The correct choices to include in the change-of-shift report are A, B, and D. Choice A is important to communicate as it highlights that the physical therapist did not ambulate the client due to difficulties with the skin barrier and fistula drainage. Choice B is crucial as it explains the specific issue with the skin barrier, emphasizing that it stays intact when the client is supine but loosens when standing. Choice D is essential to include as it informs about the upcoming visit from the wound care nurse. Choices C and E, although relevant to the client's well-being, are not directly related to the current care plan and should not be included in the report.