Nokea
Which clinical situation should the nurse identify as an example of slander?
- A. The primary health care provider tells a client that the nurse 'does not know anything.'
- B. The nurse tells a client that a nasogastric tube will be inserted if the client continues to refuse to eat.
- C. The nurse restrains a client at bedtime because the client gets up during the night and wanders around.
- D. The laboratory technician restrains the arm of a client refusing to have blood drawn so that the specimen can be obtained.
Correct Answer: A
Rationale: Defamation takes place when a falsehood is said (slander) or written (libel) about a person that results in injury to that person's good name and reputation. Battery involves offensive touching or the use of force by a perpetrator without the permission of the victim. An assault occurs when a person puts another person in fear of a harmful or offensive act.
You may also like to solve these questions
The nurse is preparing the client assignments for the day to a licensed practical nurse (LPN) and an unlicensed assistive personnel (UAP). Which clients should the nurse assign to the LPN because of client needs that cannot be met by UAP? Select all that apply.
- A. A client requiring frequent suctioning
- B. A client requiring a dressing change to the foot
- C. A client requiring range-of-motion exercises twice daily
- D. A client requiring reinforcement of teaching about a diabetic diet
- E. A client on bed rest requiring vital sign measurement every 4 hours
- F. A client requiring collection of a urine specimen for urinalysis testing
Correct Answer: A,B,D
Rationale: Delegation is the transferring to a competent individual the authority to perform a nursing task. When the nurse plans client assignments, he or she needs to consider the educational level and experience of the individual and the needs of the client. The LPN is trained to perform all the tasks indicated in the options; the clients who have needs that cannot be met by the UAP are those requiring suctioning, a dressing change, and reinforcement of teaching about a diabetic diet. UAP are trained to perform range-of-motion exercises, measure vital signs, and collect a urine specimen.
The post-myocardial infarction client is scheduled for a technetium-99 m ventriculography (multigated acquisition [MUGA] scan). The nurse should ensure that which item is in place before the procedure?
- A. A Foley catheter
- B. Signed informed consent
- C. A central venous pressure (CVP) line
- D. Notation of allergies to iodine or shellfish
Correct Answer: B
Rationale: MUGA is a radionuclide study used to detect myocardial infarction and decreased myocardial blood flow and to determine left ventricular function. A radioisotope is injected intravenously. Therefore, a signed informed consent is necessary. A Foley catheter and CVP line are not required. The procedure does not use radiopaque dye; therefore, allergy to iodine and shellfish is not a concern.
A hospitalized client wants to leave the hospital before being discharged by the primary health care provider (PHCP). Which action should be the next intervention for the nurse to implement?
- A. Notify the nursing supervisor of the client's plans to leave.
- B. Ask the client about transportation plans from the hospital.
- C. Arrange medication prescriptions at the client's preferred pharmacy.
- D. Discuss the potential consequences of the plans for leaving with the client.
Correct Answer: A
Rationale: The nurse notifies the nursing supervisor of the client's plan to leave without the primary PHCP's approval to ensure client safety and to help the nurse manage the situation. This will help the nurse manage the situation in a thoughtful, comprehensive manner and complete nursing interventions that include asking about transportation, arranging medication prescriptions, and discussing the risks and benefits of leaving or remaining in the hospital. The PHCP should be contacted and the client encouraged to remain until the PHCP arrives. The nurse avoids coercion, restraint, or security measures meant to prohibit the client's exit to prevent claims of false imprisonment.
The nurse has applied the patch electrodes of an automatic external defibrillator (AED) to the chest of a client who is pulseless. The defibrillator has interpreted the rhythm to be ventricular fibrillation. Which priority action should the nurse prepare to implement next?
- A. Administer rescue breathing during the defibrillation.
- B. Perform cardiopulmonary resuscitation (CPR) for 1 minute before defibrillating.
- C. Charge the machine and immediately push the 'discharge' buttons on the console.
- D. Order any personnel away from the client, charge the machine, and defibrillate through the console.
Correct Answer: D
Rationale: If the AED advises to defibrillate, the nurse or rescuer orders all persons away from the client, charges the machine, and pushes both of the 'discharge' buttons on the console at the same time. The charge is delivered through the patch electrodes, and this method is known as 'hands-off' defibrillation, which is safest for the rescuer. The sequence of charges is similar to that of conventional defibrillation. Option 1 is contraindicated for the safety of any rescuer. Performing CPR delays the defibrillation attempt.
The nurse monitors a client who has been diagnosed with brain death as a result of a severe head injury and is a potential organ donor. Which client assessment data should indicate to the nurse that the standard of care as an organ donor has been maintained?
- A. Urine output: 100mL} / \mathrm{hr
- B. \mathrm{pH of arterial blood: 7.32
- C. Capillary refill: 5 seconds
- D. Blood pressure: 90 / 48mmHg
Correct Answer: A
Rationale: Urine output at 100mL per hour indicates adequate renal perfusion and indicates that care standards as an organ donor are maintained. Clinical indicators of care below the standard include a \mathrm{pH of 7.32, indicating acidosis; capillary refill at 5 seconds, which is too slow; and hypotension, indicating an inadequate cardiac output. Guidelines that may be used and are helpful in determining organ viability are the 'rule of 100s ' in which the systolic blood pressure is maintained at 100mmHg , urine output at 100mL per hour, heart rate at 100 beats per minute, and \mathrm{PaO}_2 at 100mmHg .