Nokea
The nursing assistant hitting the client in the long-term care facility can be charged with:
- A. Negligence
- B. Tort
- C. Assault
- D. Malpractice
Correct Answer: C
Rationale: Assault is the appropriate charge in this scenario. Assault involves physically striking or touching someone inappropriately. Negligence (Choice A) refers to failing to provide proper care for the client. Tort (Choice B) is a wrongful act committed against the client or their property. Malpractice (Choice D) is the failure to perform an act that should have been done or the improper performance of an act resulting in harm to the client. Since the nursing assistant physically struck the client, the charge of assault is most fitting.
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After experiencing a traumatic event like losing a child due to poisoning, a client tells the nurse, 'I don’t want to make any new friends right now.' This is an example of which of the following indicators of stress?
- A. emotional indicator
- B. spiritual indicator
- C. sociocultural indicator
- D. intellectual indicator
Correct Answer: C
Rationale: The correct answer is C: sociocultural indicator. In this situation, the client's reluctance to make new friends after experiencing a traumatic event like losing a child due to poisoning reflects a change in their social behavior, which is influenced by sociocultural factors. This response indicates how stress can impact a person's relationships and social interactions. Choice A, emotional indicator, is incorrect because the client's statement is more related to social interactions than emotional expression. Choice B, spiritual indicator, is incorrect as the given scenario does not directly involve spiritual beliefs or practices. Choice D, intellectual indicator, is also incorrect as the client's statement does not reflect cognitive or intellectual changes but rather social aspects affected by the stressful event.
While assessing a client who is dying for signs of impending death, what should the nurse observe for?
- A. Elevated blood pressure
- B. Cheyne-Stokes respiration
- C. Elevated pulse rate
- D. Decreased temperature
Correct Answer: B
Rationale: When assessing a client for signs of impending death, the nurse should observe for Cheyne-Stokes respiration. This pattern involves rhythmic waxing and waning of respirations from very deep breathing to very shallow breathing with periods of temporary apnea. It is often associated with cardiac failure and can be a significant indicator of impending death. Elevated blood pressure and pulse rate are not typical signs of impending death; in fact, they may indicate other conditions. A decreased temperature is also not a common sign of impending death, as temperature changes can vary among individuals and may not always correlate with the dying process.
The nurse is caring for a dying client who has persistently requested that the nurse 'help her to die and be in peace.' According to the Code of Ethics for Nurses, the nurse should:
- A. Ask the client if she has signed an advance directives document.
- B. Tell the client that another nurse will be assigned to care for her.
- C. Instruct the client that only a physician can legally assist in suicide.
- D. Try to make the client as comfortable as possible, but refuse to assist in death.
Correct Answer: D
Rationale: According to the Code of Ethics for Nurses, the nurse should try to make the client as comfortable as possible but refuse to assist in death. It is not within the scope of nursing practice to assist in death, even if requested by the client. Choice A is incorrect as advance directives do not directly relate to the client's request for assistance in dying. Choice B is inappropriate as passing the responsibility to another nurse does not address the ethical dilemma at hand. Choice C is incorrect because instructing the client that only a physician can legally assist in suicide does not address the ethical considerations involved in the request. Therefore, the most appropriate action for the nurse is to provide comfort measures while upholding ethical standards and not participating in ending the client's life.
Which intervention should the nurse take first to assist a woman who states that she feels incompetent as the mother of a teenage daughter?
- A. Recommend that she discipline her daughter more strictly and consistently.
- B. Make a list of things she can do to help improve her husband.
- C. Assist the mother to identify what she believes is preventing her success and what she can do to improve.
- D. Explore with the mother what the daughter can do to improve her behavior.
Correct Answer: C
Rationale: The priority intervention for a mother who feels incompetent in parenting a teenage daughter is to assist her in identifying the factors contributing to her feelings of inadequacy and help her develop better coping and mothering skills. This approach focuses on addressing the mother's emotional needs and empowering her to improve her situation. Option A is incorrect as it focuses on the daughter's discipline, which may not be the root cause of the mother's feelings. Option B is irrelevant as it focuses on improving her husband, not her parenting skills. Option D is incorrect as it shifts the focus solely to the daughter's behavior, neglecting the mother's emotional needs and self-improvement.
A contraindication for topical corticosteroid use in a client with atopic dermatitis (eczema) is:
- A. parasitic infection
- B. fungal infection
- C. spirochetal infection
- D. viral infection
Correct Answer: D
Rationale: Topical corticosteroids are mainly used for their localized effects. When treating atopic dermatitis with a steroidal preparation, there is a risk of the site being vulnerable to invasion by organisms. Viruses like herpes simplex or varicella zoster pose a threat of disseminated infection. Therefore, viral infection is a contraindication for topical corticosteroid use in clients with atopic dermatitis. It is crucial to educate clients using topical corticosteroids to avoid crowds or people with infections and to promptly report any signs of infection. Choices A, B, and C (parasitic, fungal, and spirochetal infections) are not typically contraindications for topical corticosteroid use in the context of atopic dermatitis, as these agents do not pose the same risk of disseminated infection or systemic effects as viral infections.