Nokea
Nurse observes assistive personnel (AP) reprimanding a client for not using urinal properly. The AP tells him she will put a diaper on him if he doesn't use urinal more carefully next time. Which of the following torts is 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 causes another person to fear that they will be touched in a harmful or offensive manner. In this scenario, the AP's threat to put a diaper on the client if he doesn't use the urinal properly next time is an intentional act that instills fear in the client. This threat constitutes assault because it creates a reasonable apprehension of harmful or offensive contact.
Choice B (Battery) involves actual physical contact without consent, which is not present in this scenario. Choice C (False imprisonment) involves restricting someone's freedom of movement, which is not evident here. Choice D (Invasion of privacy) pertains to disclosing private information, which is not the issue at hand. Therefore, the correct answer is A as it best aligns with the scenario presented.
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Nurse enters a client's room & finds him sitting in his chair. He states, 'I fell in the shower, but I got myself back up & into my chair.' How should nurse document this in client's chart?
- A. Client fell in shower
- B. Client states he fell in shower & was able to get himself back into chair
- C. Nurse shouldn't document this info in chart b/c she didn't witness the fall
- D. Client fell in shower but is now resting comfortably
Correct Answer: B
Rationale: The correct answer is B. The nurse should document the client's statement accurately without assuming the fall occurred. This option reflects the client's own account of the situation and acknowledges his ability to self-recover. Choice A assumes the fall without confirmation. Choice C is incorrect as it is important to document client reports for continuity of care. Choice D adds unnecessary information not provided by the client.
Nurse educator is discussing facility protocol for tornados with staff. Which should nurse include in instructions? (Select all that apply.)
- A. Open doors to client rooms
- B. Place blankets over clients who are confined to beds
- C. Move beds away from windows
- D. Draw shades & close drapes
- E. Relocate ambulatory clients in hallways back to rooms
Correct Answer: B,C,D
Rationale: The correct answers are B, C, and D. B: Placing blankets over confined clients helps protect them from debris. C: Moving beds away from windows reduces the risk of injury from shattered glass. D: Drawing shades and closing drapes can prevent glass from shattering and flying into the room. A: Opening doors to client rooms can increase the risk of debris entering and injuring clients. E: Relocating ambulatory clients back to rooms can expose them to more danger in case of a tornado.
Nurse reviewing CDC's immunization recommendations with parents of 2 preschoolers. Which recommendations should nurse include in this discussion? (Select all that apply.)
- A. Haemophilus influenzae type b
- B. Varicella
- C. Polio
- D. Hepatitis A
- E. Seasonal influenza
Correct Answer: B,C,E
Rationale: The correct answers are B (Varicella), C (Polio), and E (Seasonal influenza). Varicella and seasonal influenza vaccines are recommended for preschoolers by the CDC to prevent the spread of these contagious diseases. Polio vaccine is important for preventing polio, a potentially serious disease that can be prevented through vaccination. Haemophilus influenzae type b, Hepatitis A, and the other choices are not typically part of the CDC's routine immunization recommendations for preschoolers. It is crucial for the nurse to include discussions on Varicella, Polio, and Seasonal influenza vaccines to ensure the children are protected from these preventable diseases.
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.
Nursing instructor reviewing documentation with students. Which of the following legal guidelines should they follow when documenting in client record? (Select all that apply.)
- A. Cover errors with correction fluid, & write in correct info
- B. Put date & time on all entries
- C. Document objective data, leaving out opinions
- D. Use as many abbreviations as possible
- E. Wait until the end of shift to document
Correct Answer: B, C
Rationale: Correct Answer: B, C
Rationale:
B: Putting date & time on all entries is crucial for legal purposes to establish timeline of events.
C: Documenting objective data without opinions ensures accuracy and prevents subjective bias.
Summary:
A: Covering errors with correction fluid is not recommended as it can be seen as tampering with records.
D: Using excessive abbreviations can lead to misinterpretation and errors in documentation.
E: Waiting until the end of the shift to document can result in missing crucial information or delayed updates.