Nokea
The nurse is caring for an elderly woman who has had a fractured hip repaired. In the first few days following the surgical repair, which of the following nursing measures will best facilitate the resumption of activities for this client?
- A. Arranging for the wheelchair
- B. Asking her family to visit
- C. Assisting her to sit out of bed in a chair qid
- D. Encouraging the use of an overhead trapeze
Correct Answer: D
Rationale: The trapeze promotes upper body strength and mobility, aiding recovery.
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The physician has ordered a 2-gram sodium diet for a client with hypertension. Which food should be limited due to its sodium content?
- A. Potato chips
- B. Baked chicken
- C. Steamed broccoli
- D. Fresh apple
Correct Answer: A
Rationale: Potato chips are high in sodium often 120-180 mg per ounce exceeding a 2-gram (2000 mg) daily limit for hypertension, necessitating restriction to control blood pressure. Baked chicken, steamed broccoli, and fresh apples have minimal natural sodium, fitting the diet. Nurses educate clients on hidden sodium in processed snacks, promoting fresh alternatives to reduce cardiovascular strain, aligning with therapeutic goals for long-term health management.
You are the nurse working with an elderly, competent client who refuses a vitamin B injection ordered by the physician. The family insists that this injection be given, and you give it while the client is objecting. Even though the client improves, the client contacts a lawyer. From your knowledge of nursing and the law, you realize that you:
- A. did the right thing because the client improved.
- B. should have had the family put their request in writing.
- C. have commited an assault against the client.
- D. have committed an act of battery against the client.
Correct Answer: D
Rationale: Administering a vitamin B injection to a competent client who refuses it, despite family insistence and subsequent improvement, constitutes battery. Battery is the unlawful physical contact with a person without consent, and in healthcare, consent is a fundamental right for competent adults. The client's objection overrides family wishes, and giving the injection violates autonomy, a core ethical principle. The outcome of improvement doesn't justify the action legally or ethically. Assault involves threatening harm, whereas battery is the act itself, making this the correct classification. Getting family requests in writing or focusing on the outcome doesn't negate the lack of consent. This scenario underscores the importance of respecting patient rights and the legal consequences of disregarding them, even with good intentions.
Which of the following statement is TRUE about assault?
- A. Touching the client without consent
- B. An intentional threat
- C. Causes physical harm
- D. All of the above
Correct Answer: B
Rationale: Assault is an intentional threat (B), per law e.g., menacing gesture, no contact needed. Touching (A) is battery, harm (C) not required, all (D) oversteps. B truly defines assault's intent, making it correct.
Mr. Gary uses acupuncture along with his meds. This is an example of?
- A. Complementary therapy
- B. Alternative therapy
- C. Therapeutic touch
- D. Health promotion
Correct Answer: A
Rationale: Acupuncture with meds is complementary therapy (A) with conventional, per definition. Alternative (B) replaces, touch (C) hands, promotion (D) well-being not combo-specific. A fits integrated use, making it correct.
Mr. Gary died yesterday, His wife is not talking to anyone and prefers to be alone staring blankly at her husband's picture. This is an example of?
- A. Denial
- B. Anger
- C. Bargaining
- D. Depression
Correct Answer: D
Rationale: Not talking, staring blankly post-death is depression (D), per Kubler-Ross withdrawal, sadness dominate. Denial (A) disputes, anger (B) lashes, bargaining (C) negotiates all absent. Depression fits her isolation, making it correct.