Nokea
Adult client who is competent tells the nurse that he is thinking about leaving the hospital against medical advice. Nurse believes that this is not in client's best interest, so she administers a PRN sedative medication that the client has not requested along with his usual medication. Which of the following types of tort has the nurse committed?
- A. Assault
- B. False imprisonment
- C. Negligence
- D. Breach of confidentiality
Correct Answer: B
Rationale: The correct answer is B: False imprisonment. False imprisonment occurs when a person is confined or restrained against their will. In this scenario, the nurse's act of administering a sedative medication without the client's consent constitutes a form of restraint, therefore, it falls under false imprisonment. The nurse's action restricts the client's freedom to leave the hospital, even though the client is competent and has expressed the intention to leave. The other options are not applicable in this situation: A - Assault involves the threat of harm, C - Negligence involves a breach of duty of care, and D - Breach of confidentiality involves disclosing private information without consent.
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Nurse observes smoke coming from under door of staff lounge. Which is priority action by the nurse?
- A. Extinguish fire
- B. Pull fire alarm
- C. Evacuate the clients
- D. Close all open doors on the unit
Correct Answer: C
Rationale: The priority action for the nurse in this scenario is to evacuate the clients (Choice C). This is because ensuring the safety of the clients is the most critical responsibility in a healthcare setting. Evacuating them immediately helps prevent harm and ensures their well-being. Pulling the fire alarm (Choice B) may be necessary but not the top priority as it does not directly ensure client safety. Extinguishing the fire (Choice A) may put the nurse at risk and delay client evacuation. Closing doors (Choice D) may contain the fire but does not address the immediate need of client safety.
Nursing instructor is reviewing steps of nursing process with group of students. Students should identify which of following data as objective? (Select all that apply.)
- A. Respiratory rate of 22/min with even, unlabored respirations
- B. I can only walk 3 blocks before my legs start to hurt'
- C. Pain level 3/10
- D. Skin pink, warm, dry
- E. Urine output 300 mL/8 hr
- F. Dressing clean, dry, intact
Correct Answer: A, D, E, F
Rationale: Objective data refers to measurable and observable information.
A: Respiratory rate and breathing pattern can be directly observed and counted, making it objective data.
D: Skin color, temperature, and moisture can be seen and felt, making it objective data.
E: Urine output is quantifiable and measurable, making it objective data.
F: The cleanliness, dryness, and integrity of a dressing can be visually assessed, making it objective data.
The other choices involve subjective experiences or interpretations (B), self-reported pain level (C), or may require additional assessments beyond direct observation (G).
Nurse educator conducting parenting class for new parents. Which statement made by participant indicates need for further teaching?
- A. I will begin swimming lessons as soon as my baby can close her mouth under water
- B. Once my baby can sit up, he should be safe in bathtub
- C. I will test the temp of water before placing baby in bath
- D. Once my infant starts to push up, I will remove mobile from over the bed
Correct Answer: B
Rationale: The correct answer is B. This statement indicates a need for further teaching because it is not safe to leave a baby unattended in the bathtub even if they can sit up. Babies can easily slip or move unexpectedly, leading to a potential drowning risk. Teaching should emphasize the importance of constant supervision during bath time. Choice A is incorrect as it highlights an unsafe practice of initiating swimming lessons too early for an infant. Choice C demonstrates proper safety measures by testing water temperature. Choice D shows awareness of removing potential hazards from the infant's environment.
Nurse is completing discharge teaching to client with COPD. Client verbalizes understanding of orthopneic position when he states, 'When I have difficulty breathing at night, I will...'
- A. Lie on my back with head & shoulders elevated on a pillow
- B. Lie flat on my stomach with head to one side
- C. Sit on side of my bed & rest my arms over pillows on top of my raised bedside table
- D. Lie on my side with my weight on my hips & shoulder with my arms flexed in front of me
Correct Answer: C
Rationale: The correct answer is C: Sit on side of my bed & rest my arms over pillows on top of my raised bedside table. Orthopneic position is sitting upright with arms supported, which helps improve lung expansion and ease breathing. Choice A is incorrect as lying on the back can worsen breathing difficulties. Choice B is incorrect as lying flat on the stomach hinders breathing. Choice D is incorrect as lying on the side does not provide the same lung expansion as sitting upright.
Nurse is talking with parents of toddler. Which should nurse suggest regarding discipline?
- A. Establish consistent boundaries
- B. Place him in room with door closed
- C. Have him learn by trial & error
- D. Use favorite snacks as rewards
Correct Answer: A
Rationale: The correct answer is A: Establish consistent boundaries. This is important in toddler discipline as it provides structure and teaches the child what behaviors are acceptable. Consistency helps in setting clear expectations and enforcing consequences. Option B is incorrect as isolation can lead to feelings of abandonment. Option C is incorrect as trial and error may not provide clear guidance for the child. Option D is incorrect as using food rewards may lead to unhealthy eating habits.