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Nurse Edna admits a patient from the ER to the medical unit. The patient is very restless with IV lines and a urinary catheter. She was put to bed and the nurse applied a body restraint without the doctor's order. Nurse Edna's action can be liable for _____.
- A. invasion of privacy
- B. assault
- C. battery
- D. neglect
Correct Answer: C
Rationale: Battery occurs when there is an intentional harmful or offensive contact with a person without their consent. In this scenario, Nurse Edna applied a body restraint to the patient without the doctor's order, which constitutes unauthorized physical contact. The patient did not give consent for the restraint, and Nurse Edna's action could be considered battery. It is important for healthcare providers to obtain proper authorization before using any form of physical restraint on a patient to avoid legal implications such as battery.
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A patient presents with redness, pain, and photophobia in the left eye. Slit-lamp examination reveals ciliary injection, corneal edema, and a mid-dilated pupil with fixed reaction to light. Which of the following conditions is most likely responsible for this presentation?
- A. Anterior uveitis
- B. Acute angle-closure glaucoma
- C. Endophthalmitis
- D. Corneal abrasion
Correct Answer: A
Rationale: The presentation described in the question is characteristic of anterior uveitis. Anterior uveitis is inflammation of the iris and ciliary body in the eye. Patients typically present with symptoms such as redness, pain, and photophobia. Slit-lamp examination findings include ciliary injection (redness and engorgement of blood vessels in the ciliary body), corneal edema (swelling of the cornea), and a mid-dilated pupil with a fixed reaction to light due to involvement of the iris muscles. These features differentiate anterior uveitis from other conditions. Treatment of anterior uveitis may involve topical steroids and cycloplegics to reduce inflammation and alleviate symptoms.
Nurse Mary randomly seleted individuals in the community who will be part of a project. Which of the following ethical principle is observed by the nurse?
- A. Autonomy
- B. Confidentiality
- C. Beneficence
- D. Fair treatment
Correct Answer: A
Rationale: By randomly selecting individuals in the community for the project, Nurse Mary is upholding the ethical principle of autonomy. Autonomy refers to respecting individuals' right to make their own decisions and choices. In this scenario, Nurse Mary is not imposing her own preferences or biases but rather allowing individuals in the community to have an equal opportunity to participate in the project. Random selection ensures that the process is fair and gives everyone an equal chance to be involved, respecting their autonomy.
Nurse bea wants to pursue higher education in Nursing for her career advancement. Aside from enrolling in graduate school, which of the following she could enhance her career?
- A. Participates in professional organization
- B. Attends seminars.
- C. Conduct research
- D. Attends symposium
Correct Answer: A
Rationale: Participating in professional organizations can be a valuable way for Nurse Bea to enhance her career in nursing aside from enrolling in graduate school. Professional organizations provide networking opportunities, access to resources and information, opportunities for professional development through workshops and conferences, and a platform for engaging in advocacy efforts to promote the nursing profession. By being an active member of a professional organization, Nurse Bea can further her knowledge, skills, and connections within the nursing field, which can contribute to her career advancement.
A postpartum client with a history of breast augmentation expresses concerns about breastfeeding difficulties. What nursing intervention should be prioritized to support successful breastfeeding in this situation?
- A. Providing education on techniques to promote milk production and let-down
- B. Recommending supplemental formula feedings to ensure adequate nutrition
- C. Encouraging the client to avoid breastfeeding to prevent discomfort
- D. Referring the client to a lactation consultant for specialized support
Correct Answer: D
Rationale: Referring the client to a lactation consultant for specialized support should be prioritized to support successful breastfeeding in this situation. Breast augmentation surgery may impact milk production, let-down reflex, and proper latch due to alterations in breast tissue and nerve pathways. A lactation consultant can provide individualized guidance and support to address these specific challenges. Additionally, the consultant can assist in establishing a breastfeeding plan tailored to the client's unique needs, helping to optimize the breastfeeding experience for both the mother and the baby. It is crucial to seek expert assistance in navigating any potential difficulties that may arise from breastfeeding after breast augmentation to promote successful breastfeeding outcomes.
A postpartum client reports severe headache, visual disturbances, and epigastric pain. Which nursing action is most appropriate?
- A. Encouraging the client to rest in a dark, quiet room
- B. Providing acetaminophen for headache relief
- C. Assessing blood pressure and other vital signs
- D. Offering a massage to relieve muscle tension
Correct Answer: C
Rationale: The most appropriate nursing action in this situation is to assess the client's blood pressure and other vital signs. The client's symptoms of severe headache, visual disturbances, and epigastric pain could be indicative of preeclampsia or eclampsia, which are serious conditions that require immediate medical attention. Checking the blood pressure and other vital signs will help determine if the client's symptoms are related to abnormal blood pressure levels, which is critical in identifying and managing hypertensive disorders in postpartum clients. Once the assessment is completed, appropriate medical interventions can be initiated promptly if necessary.